Gordon Suckley

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Independent investigation
into the death of
Mr Gordon Suckley, a prisoner
at HMP Channings Wood,
on 15 July 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
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Summary
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 May 2023, Mr Gordon Suckley was sentenced to 15 years and three months
imprisonment for sexual offences. He died of aspiration pneumonia (infection of the
lungs) caused by pseudo bowel obstruction (when the intestines have symptoms of
a blockage but there is not a physical blockage) which, in turn, was caused by
hiatus hernia (when part of the stomach moves up in the chest). Frailty of old age
and chronic kidney disease also contributed to but did not cause his death. He was
89 years old when he died on 15 July 2025, in hospital. We offer our condolences to
Mr Suckley’s family and friends.
4. The Ombudsman’s office wrote to Mr Suckley’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
5. NHS England commissioned an independent clinical reviewer, to review Mr
Suckley’s clinical care at Channings Wood. The clinical reviewer’s report is attached
as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Suckley received at
Channings Wood was of a reasonable standard and equivalent to that which he
could have expected to receive in the community. However, he found that a
quantitative faecal immunochemical test (qFIT - used to detect blood in faeces) was
requested but never followed up. We make the following recommendation:
The Head of Healthcare should ensure that there is a robust safety net
procedure in place to ensure that qFITs take place as requested.
7. The clinical reviewer also made recommendations not related to Mr Suckley’s death
that the Head of Healthcare will wish to address.
8. The PPO investigator investigated the non-clinical issues relating to Mr Suckley’s
care.
9. We did not find any non-clinical issues of sufficiently serious concern to make a
recommendation but bring the below to the Governor’s attention in relation to the
liaison with Mr Suckley’s family following his death.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
Prisons and Probation Ombudsman 1
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Governor to note
11. The prison contacted Mr Suckley’s family before his death and told them when he
died in a timely manner. However, after this, there was a miscommunication about
who was the allocated family liaison officer (they had just completed their training)
and, consequently, no one contacted his family again until early August to offer
follow up support. We bring this to the Governor’s attention to ensure new family
liaison officers are appropriately supported.
Adrian Usher January 2026
Prisons and Probation Ombudsman
Inquest
12. The inquest into Mr Suckley’s death finished on 29 June 2026 and concluded that
Mr Suckley died of 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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