Colin Milner

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Colin Milner,
a prisoner at HMP Wandsworth,
on 5 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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. On 15 August 2022, Mr Colin Milner was sentenced to one year and four months in
prison for public order offences. He was granted conditional release on 23 January
2023, but was recalled on 28 January 2023 for breaching his licence conditions.
4. Mr Milner died from metastatic oesophageal cancer on 5 July 2023 while a prisoner
at HMP Wandsworth. He was 56 years old. We offer our condolences to Mr Milner’s
family and friends.
5. The PPO family liaison officer wrote to Mr Milner’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.
6. The PPO investigator investigated the non-clinical issues relating to Mr Milner’s
care. We did not find any non-clinical issues of concern.
7. NHS England commissioned an independent clinical reviewer to review Mr Milner’s
clinical care at HMP Wandsworth. He concluded that the clinical care Mr Milner
received at Wandsworth was equivalent to what he could have expected to receive
in the community. However, he found that there was a delay in Mr Milner’s initial
suspected cancer assessment at HMP Rochester and this aspect of his care was
not equivalent. The clinical reviewer made two recommendations not directly related
to Mr Milner’s death that the Head of Healthcare will wish to consider.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
Oxyleas Trust pointed out some factual inaccuracies in the clinical reviewer’s report,
and this has been amended accordingly.
9. Mr Milner’s family received a copy of the initial report. They did not make any
comments.
10. At the inquest held on 25 June 2024, the coroner concluded that Mr Colin Milner
died of natural causes.
Adrian Usher June 2024
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
OFFICIAL - FOR PUBLIC RELEASE
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