John Cannan

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Independent investigation into
the death of Mr John Cannan,
a prisoner at HMP Full Sutton,
on 6 November 2024
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, 2025
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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 1989, Mr John Cannan was sentenced to life imprisonment for murder. He died
of a ruptured abdominal aortic aneurysm on 6 November 2024, while a prisoner at
HMP Full Sutton. He was 70 years old. We offer our condolences to Mr Cannan’s
family and friends.
4. The Ombudsman’s office wrote to Mr Cannan’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
Cannan’s clinical care at Full Sutton.
6. The clinical reviewer concluded that the clinical care Mr Cannan received at Full
Sutton was of a good standard and equivalent to that which he could have expected
to receive in the community. She found that although Mr Cannan made unwise
decisions to refuse healthcare treatments despite being warned of the risks, she
was satisfied that he had the mental capacity to make such decisions. She
concluded that Mr Cannan was managed with respect and cared for by confident,
competent staff. The clinical reviewer made no recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Cannan’s
care. We found no significant non-clinical issues and make no recommendations.
Governor to note
8. There was a delay in the nurse attending the emergency response because the
healthcare gate was incorrectly double locked. Full Sutton told us that this was a
one-off mistake. Mr Cannan had a DNACPR in place. As the delay did not affect the
outcome for Mr Cannan, we draw it to the Governor’s attention to prevent a
recurrence.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
10. Mr Cannan’s family received a copy of the draft report. They did not make any
comments.
Prisons and Probation Ombudsman 1
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11. At an inquest held on 27 March 2025, the Coroner concluded that Mr Cannan died
of natural causes.
Adrian Usher June 2025
Prisons and Probation Ombudsman
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
OFFICIAL - FOR PUBLIC RELEASE