Gary Winters

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Gary Winters,
a prisoner at HMP Whatton,
on 25 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
OFFICIAL - FOR PUBLIC RELEASE
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
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. In July 2021, Mr Gary Winters was sentenced to ten years imprisonment for sexual
offences. He died in hospital of lung cancer on 25 November 2025, while a prisoner
at HMP Whatton. He was 65 years old. We offer our condolences to those who
knew him.
4. The prison was unable to trace a next of kin for Mr Winters. Therefore, the
Ombudsman’s office did not contact anyone about this investigation.
5. NHS England commissioned an independent clinical reviewer to review Mr Winters’
clinical care at HMP Whatton. The clinical reviewer’s report is attached as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Winters received at
Whatton was of a reasonable standard and equivalent to that which he could have
expected to receive in the community. Despite Mr Winters receiving a diagnosis of
advanced cancer only a month before he died, she found that the care provided by
the GPs at Whatton was thorough and of a good standard. They had long
suspected Mr Winters had cancer but extensive investigations had shown no sign of
this. The clinical reviewer made four recommendations not related to Mr Winters’
death that the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Winters’
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They did not find any factual inaccuracies.
Adrian Usher April 2026
Prisons and Probation Ombudsman
Inquest
10. At the inquest held on 10 June 2026, the Coroner concluded that Mr Winters died
from natural causes.
Prisons and Probation Ombudsman 1
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