Lee Amos

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Lee Amos,
a prisoner at HMP Oakwood,
on 22 April 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
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
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. On 7 April 2009, Mr Lee Amos was sentenced to life in prison with a minimum term
of 35 years (later varied on appeal to 32 years) for murder and attempted murder.
4. Mr Amos died in hospital of cardiac arrest caused by ventricular fibrillation (rapid,
erratic heartbeats that cause the heart to abruptly stop pumping blood to the body)
due to cardiomegaly (enlarged heart) on 28 April 2024, while a prisoner at HMP
Oakwood. He was 48 years old. We offer our condolences to Mr Amos’ family and
friends.
5. The Ombudsman’s office wrote to Mr Amos’ brother to explain the investigation and
to ask if he had any matters he wanted us to consider. He did not respond.
6. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
7. NHS England commissioned an independent clinical reviewer to review Mr Amos’
clinical care at HMP Oakwood.
8. Mr Amos’ death was sudden and unexpected. Although he had Crohn’s disease, he
managed this well in prison and it was not related to his death. There was no
indication of any other healthcare issues for Mr Amos and he had no recorded
history of heart disease. Prison and healthcare staff did not report any concerns for
him in the time before his death.
9. The clinical reviewer found that Mr Amos received a good standard of health care
that was equivalent to that which he might expect to receive in the community. She
made one recommendation around care planning for long-term conditions that the
Head of Healthcare will wish to address.
10. The PPO investigator investigated the non-clinical issues relating to Mr Amos’ care.
We did not find any non-clinical issues of concern.
11. We make no recommendations.
Inquest
12. The inquest into Mr Amos’ death concluded on the 20 August 2025. The coroner
confirmed that Mr Amos died of natural causes.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Adrian Usher
Prisons and Probation Ombudsman September 2025
.
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