Ian Stokes

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Ian Stokes,
a prisoner at HMP Rye Hill,
on 27 December 2021
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, 2025
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
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. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr Ian Stokes died in a hospice on 27 December 2021 of pneumonia while a
prisoner at HMP Rye Hill. He also had squamous cell carcinoma nasal septum
(skin cancer on his nose) which did not cause but contributed to his death. Mr
Stokes was 55 years old. I offer my condolences to Mr Stokes’ family and friends.
4. The clinical reviewer concluded that the clinical care Mr Stokes received at HMP
Rye Hill was of a very good standard and equivalent to that which he could have
expected to receive in the community. She made three recommendations about
record keeping and medication risk assessments, which the Head of Healthcare will
need to address.
5. We make no recommendations.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
6. NHS England commissioned an independent clinical reviewer to review Mr Stokes’
clinical care at HMP Rye Hill.
7. The PPO investigator has investigated non-clinical issues, including Mr Stokes’
location, the security arrangements for his hospital escorts, liaison with his family
and whether compassionate release was considered.
8. The PPO family liaison officer wrote to Mr Stokes’ next of kin, his son, to explain the
investigation. He did not respond to our letter.
9. We shared the initial report with HM Prison and Probation Service. They identified
one factual inaccuracy, which we have amended.
Previous deaths at HMP Rye Hill
10. Mr Stokes was the 14th prisoner to die at HMP Rye Hill since December 2019. Of
these deaths, all were from natural causes. There are no similarities between our
findings in the investigation into Mr Stokes’ death and our investigation findings for
the previous deaths.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
11. In March 2016, Mr Ian Stokes was sentenced to 23 years in prison for rape. He
was transferred to HMP Rye Hill in August 2016.
12. On 28 July 2020, Mr Stokes saw a prison GP because he had an abscess in his left
nostril. The GP recorded that Mr Stokes had a lesion, with bleeding when touched
and mucus that dripped. He prescribed antibiotics and referred Mr Stokes to an
ear, nose and throat (ENT) consultant and the Arden Centre for cancer.
13. On 19 August, Mr Stokes had a fiberscope (a flexible instrument used to look down
difficult to reach places with a camera) which identified a mass. He was referred for
a CT scan (a computerised moving x-ray).
14. On 15 September, Mr Stokes had a biopsy taken of his nasal lesion.
15. On 1 October, Mr Stokes was diagnosed squamous cell carcinoma nasal septum
and premaxilla, (extensive skin cancer of the nasal cavity and involving the cheek
bones).
16. On 5 November, Mr Stokes was told that his cancer was not curable and given a life
expectancy of between six months and two years. He started chemotherapy and
was offered support from the Macmillan nursing team.
17. On 3 December, an application for Mr Stokes’ early release on compassionate
grounds (ERCG) was submitted to the Public Protection Casework Section (PPCS)
of Her Majesty’s Prison and Probation Service.
18. On 12 January 2021, Mr Stokes’ ERCG application was refused because he was
still capable of reoffending and there was no medical evidence that his life
expectancy was three months or less.
19. On 24 May, Mr Stokes signed a form setting out his end of life care wishes that he
did not wish anyone to resuscitate him if his heart or breathing stopped.
20. On 26 July, after discussion with his oncologist, Mr Stokes’ chemotherapy was
stopped.
21. On 4 August, Mr Stokes started immunotherapy (medicine to stimulate the immune
system and to help it recognise and destroy cancer cells), which he received every
two weeks.
22. On 10 August, Rye Hill decided, for medical reasons, not to cuff Mr Stokes when
escorted to appointments.
23. On 22 December, Mr Stokes was admitted to a hospice.
24. The next day, Rye Hill resubmitted an ERCG application to PPCS.
25. On 26 December, Rye Hill contacted Mr Stokes’ son, to arrange for him to visit him
at the hospice.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
26. Mr Stokes’ health deteriorated further, and he died on 27 December of pneumonia.
Mr Stokes also had squamous cell carcinoma of the nasal cavity, which did not
cause but contributed to his death.
Inquest
27. At an Inquest hearing on 6 June 2022, Mr Stokes’ cause of death was determined
to be natural causes.
Caroline Mills
Assistant Ombudsman March 2025
4 Prisons and Probation Ombudsman
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