Gary Beaudro

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Independent investigation into
the death of Mr Gary Beaudro,
a prisoner at HMP Bristol,
on 27 June 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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OFFICIAL - FOR PUBLIC RELEASE
© 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. On 26 May 2023, Mr Gary Beaudro was sentenced to 30 months in prison for
indecent assault. He died from multiple cerebral embolic infarcts (strokes, caused
by blood clots travelling to the brain), caused by pancreatic adenocarcinoma with
liver metastases (pancreatic cancer which has spread to the liver) on 27 June 2025,
while a prisoner at HMP Bristol. He was 76 years old. We offer our condolences to
Mr Beaudro’s family and friends.
4. The Ombudsman’s office contacted Mr Beaudro’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
Beaudro’s clinical care at HMP Bristol. The clinical review is attached as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Beaudro received at Bristol
was of a good standard and at least equivalent to that which he could have
expected to receive in the community. He found that Mr Beaudro was promptly
referred to secondary services when he presented with anaemia, and found
integrated care between healthcare teams at Bristol and Ashfield. He made no
recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Beaudro’s
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
10. Mr Beaudro’s family received a copy of the draft report. They did not make any
comments.
11. In an inquest held on 8 June 2026, the Coroner concluded that Mr Beaudro died of
natural causes.
Adrian Usher February 2026
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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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
OFFICIAL - FOR PUBLIC RELEASE