Graham Stridgeon

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Independent investigation
into the death of
Mr Graham Stridgeon,
a prisoner at HMP Wymott,
on 16 February 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 2018, Mr Graham Stridgeon was sentenced to five years imprisonment for sexual
offences. In 2019, after appeal, the sentenced was changed to an extended
sentence of five years and ten months imprisonment and three years on licence. Mr
Stridgeon was briefly released in August 2024, but was recalled to prison the
following month.
4. Mr Stridgeon died of pneumonia (infection to the lungs) on 16 February 2025, in
hospital while a prisoner at HMP Wymott. Diabetes (disease that causes high blood
sugar levels) contributed to but did not cause his death. He was 70 years old. We
offer our condolences to those who knew Mr Stridgeon.
5. NHS England commissioned an independent clinical reviewer to review Mr
Stridgeon’s clinical care at HMP Wymott.
6. The clinical reviewer concluded that the clinical care Mr Stridgeon received at
Wymott was partially equivalent to that which he could have expected to receive in
the community. She noted that Mr Stridgeon had appropriate reviews and care for
his long-term conditions. However, she found that healthcare staff missed signs of
sepsis and that they should have transferred Mr Stridgeon to hospital in the evening
of 11 February, rather than waiting until the next morning. We make the following
related recommendations:
The Head of Healthcare should ensure that all healthcare staff undertake the
deteriorating patient learning module and ensure annual updates are
completed.
The Head of Healthcare should ensure that healthcare staff record prisoners’
physical observations and NEWS2 scores in their clinical record.
7. The PPO investigator investigated the non-clinical issues relating to Mr Stridgeon’s
care. We make no recommendations although we note the apparent lack of
interaction with Mr Stridgeon in the last months of his life as detailed below.
Governor to Note
8. There are no records of any meaningful interaction between Mr Stridgeon and
prison staff, including keyworkers, in the last four months of his life. When asked by
the investigator, the prison was unable to identify a member of staff who could tell
us how Mr Stridgeon had seemed during this time.
9. The prison explained that, due to staff shortages, they had agreed with the Prison
Group Director to deliver a restricted regime which prioritised unlocking prisoners
Prisons and Probation Ombudsman 1
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and delivering education and workshops. They also said they aim to deliver 89
keyworker sessions per week (out of 387 when fully staffed), which they have
consistently surpassed during the last four months. Keywork is prioritised for
prisoners who are transgender, young adults, new to the prison or are on an
imprisonment for public protection sentence. Therefore, Mr Stridgeon did not qualify
for these sessions. We bring the apparent lack of interaction with Mr Stridgeon to
the Governor’s attention as they work towards reinstating a full keyworker regime.
10. The initial report was shared with HM Prison and Probation Service (HMPPS) and
Practice Plus Group. They pointed out one factual inaccuracy in the clinical
reviewer’s report, which has now been amended.
Adrian Usher July 2025
Prisons and Probation Ombudsman
Inquest
The inquest into Mr Stridgeon’s death was held on 25 March 2026. The Coroner
concluded that Mr Stridgeon 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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