Anthony Milgate

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Independent investigation into
the death of Mr Anthony Milgate,
a prisoner at HMP Swaleside,
on 14 July 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) 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.
3. Mr Anthony Milgate was sentenced to life imprisonment in 2003 for sexual offences
and false imprisonment. He died from gastric cancer, which had spread, and acute
renal failure while a prisoner at HMP Swaleside. He was 64 years old. We offer our
condolences to his family and friends.
4. The PPO family liaison officer wrote to Mr Milgate’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
had no questions but asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer, to review Mr
Milgate’s clinical care at Swaleside. The clinical reviewer concluded that the clinical
care Mr Milgate received at Swaleside was equivalent to that which he could have
expected to receive in the community. The clinical review is attached as Annex 1.
6. The clinical reviewer made three recommendations which were not related to Mr
Milgate’s death but which the Head of Healthcare will want to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Milgate’s
care. We did not find any non-clinical issues of concern. We make no
recommendations.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
9. The next of kin received a copy of the draft report. They did not make any
comments.
10. This version of my report, published on my website, has been amended to remove
the names of staff and prisoners involved in my investigation.
Adrian Usher April 2023
Prisons and Probation Ombudsman
Inquest
11. The inquest into Mr Milgate’s death was held on 21 March 2024 and a verdict of
natural causes was recorded. The coroner concluded that Mr Milgate’s death was
due to gastric cancer with metastases and acute renal failure. Mr Milgate also had
skin cancer of the nose.
Prisons and Probation Ombudsman 1
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OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE