Kenneth Cox

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Kenneth Cox,
a prisoner at HMP Norwich,
on 7 January 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 March 2024, Mr Kenneth Cox was sentenced to six months in prison for a sexual
offence. In September, he was sentenced to a further 27 months in prison for
another sexual offence. He died of hemopericardium (a condition that causes a
build-up of blood around the heart, which compresses the heart) caused by an
aortic dissection (a tear in the wall of the main artery), on 7 January 2025, while a
prisoner at HMP Norwich. Hypertension (high blood pressure) also contributed to
his death. He was 66 years old. We offer our condolences to Mr Cox’s family and
friends.
4. The Ombudsman’s office wrote to Mr Cox’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 Cox’s
clinical care at Norwich. The clinical reviewer’s report is attached as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Cox received at Norwich
was variable and partially equivalent to that which he could have expected to
receive in the community. The clinical reviewer found evidence of good practice in
how healthcare staff communicated with Mr Cox, prompting him to manage his
health needs and repeatedly encouraging him to take medication for his high blood
pressure. The clinical reviewer was satisfied that appropriate care plans were in
place to manage his hypertension. However, she also identified areas for
improvement. She found no evidence of a care plan or any action taken following
Mr Cox’s abnormal electrocardiogram (ECG – used to measure the electrical
activity of the heart) in December 2024. We make the following recommendations:
• The Head of Healthcare should ensure that a clear management plan is
documented when abnormal test results are received.
• The Head of Healthcare should ensure that prisoners with complex health
needs are discussed at multi-disciplinary meetings.
7. The clinical reviewer also made two other recommendations not related to Mr Cox’s
death that the Head of Healthcare will wish to address.
8. The PPO investigator investigated the non-clinical issues relating to Mr Cox’s care.
9. We did not find any non-clinical issues of concern.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
10. We shared the initial report with HM Prison and Probation Service (HMPPS) and
the prison’s healthcare provider, HCRG Care Group. They did not find any factual
inaccuracies and their action plan is an additional annex to this report.
Adrian Usher
Prisons and Probation Ombudsman May 2026
Inquest
11. At the inquest, held on 29 January 2026, the Coroner concluded that Mr Cox died
from natural causes.
2 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