Ann Browning

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Independent investigation into
the death of Ms Ann Browning,
a prisoner at HMP Send,
on 30 November 2025
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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© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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. In August 2011, Ms Ann Browning was sentenced to life imprisonment for murder.
She died in hospital on 30 November 2025, while a prisoner at HMP Send. The
Coroner gave the provisional cause of death as lung cancer. She was 68 years old.
We offer our condolences to Ms Browning’s family and friends.
4. The Ombudsman’s office wrote to Ms Browning’s son to explain the investigation
and to ask if he had any matters he wanted us to consider. We mistakenly wrote
that we were investigating Ms Browning’s death as a post-release death. Mr
Browning’s son asked us to correct this as although Ms Browning had been
temporarily released to hospital, she was still in the custody of HMP Send when she
died. We apologised for this error by email.
5. NHS England commissioned an independent clinical reviewer to review Ms
Browning’s clinical care at HMP Send.
6. The PPO investigator investigated the non-clinical issues relating to Ms Browning’s
care. She spoke to two prisoners who knew Ms Browning, who said that Ms
Browning’s health deteriorated in the weeks leading up to her hospitalisation. They
said they had to provide her with support with daily activities and that they raised
concerns with healthcare staff and wing officers about her deteriorating condition.
Although these concerns were escalated, they did not see any changes to Ms
Browning’s care prior to her admission to hospital. They were particularly concerned
that Ms Browning was missing her GP appointments because she struggled both
physically and mentally to attend them.
7. We did not find any non-clinical issues of concern.
8. The clinical reviewer concluded that the clinical care Ms Browning received at Send
was of a good standard and equivalent to that which she could have expected to
receive in the community. He found that Ms Browning had good mental health
support and was appropriately referred to a GP when she developed physical
symptoms. However, Ms Browning repeatedly did not attend medical appointments,
and healthcare staff did not explore the reasons why. We recommend:
The Head of Healthcare should ensure that a robust system is in place to
monitor missed healthcare appointments and that staff routinely explore and
record reasons for non-attendance, to identify and address any barriers to
attendance.
9. The clinical reviewer made three other recommendations not related to Ms
Browning’s death that the Head of Healthcare will wish to address.
Prisons and Probation Ombudsman 1
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Good Practice
10. On 30 October, Ms Browning was granted Release on Temporary Licence (ROTL)
using a Special Purpose Licence (SPL) under medical grounds and remained on
ROTL until her death. This meant that she was temporarily released for medical
treatment and was not restrained or guarded by officers. This provided Ms
Browning and her family privacy in her final moments and ensured both dignity and
respect in death.
11. We shared our initial report with HMPPS and the prison’s healthcare provider,
Central and North West London NHS Foundation Trust (CNWL). They found no
factual inaccuracies. CNWL provided an action plan which is annexed to this report.
Adrian Usher May 2026
Prisons and Probation Ombudsman
Inquest
At the inquest, held on 18 June 2026, the Coroner concluded that Ms Browning died from
natural causes.
2 Prisons and Probation Ombudsman
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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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