Myles Filose

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Independent investigation into
the death of Mr Myles Filose,
following his release from HMP
Winchester, on 7 April 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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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. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
3. 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.
4. Mr Myles Filose died of peritonitis caused by a small bowel perforation on 7 April
2025, following his release from HMP Winchester on 2 April. He was 43 years old.
We offer our condolences to those who knew him.
5. The clinical reviewer concluded that the care Mr Filose received in the lead up to his
release from Winchester was not of the required standard and therefore not
equivalent to that which would have been received in the wider community.
6. The clinical reviewer had concerns regarding Mr Filose’s mental capacity and ability
to reasonably decline support. Mr Filose was presumed to have capacity when he
declined a referral to NHS Reconnect (a care after custody service that seeks to
improve the continuity of care of people leaving prison with an identified health
need) and there is no evidence that he received a formal mental capacity
assessment at Winchester.
Recommendations
The Head of Healthcare at Winchester should ensure that when an individual
exhibits impaired cognition, mental distress, confusion or unusual behaviour,
a formal Mental Capacity Act assessment is completed and documented, with
evidence of best-interest decision-making if capacity is lacking.
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The Investigation Process
7. HMPPS notified us of Mr Filose’s death on 9 April 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Filose’s prison
and probation records.
9. NHS England commissioned an independent clinical reviewer to review Mr Filose’s
clinical care at the prison.
10. We informed HM Coroner for Hampshire of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report. The Coroner informed us that there would be no inquest held for Mr Filose’s
death.
11. The Ombudsman’s office contacted Mr Filose’s uncle to explain the investigation
and to ask if he had any matters he wanted us to consider. He asked what provision
was in place for Mr Filose’s release and whether he was offered accommodation.
He also wanted to know whether Mr Filose’s health was assessed prior to his
release and whether he was displaying any symptoms. His concerns have been
addressed in our report and the clinical review.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
13. Mr Filose’s family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Winchester
14. HMP Winchester is a category B prison, with a small separate category C facility. It
holds convicted and remanded male prisoners. Practice Plus Group is the
healthcare and substance misuse provider.
Probation Service
15. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services where
appropriate. Post-release, the Probation Service supervises people throughout their
licence period and post-sentence supervision.
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Key Events
Background
16. On 14 February 2025, Mr Myles Filose was convicted of malicious wounding and
was sentenced to 4 months in prison. He was sent to HMP Winchester. It was not
his first time in prison.
Pre-release planning
17. On 14 February, Mr Filose attended his reception screening with a nurse. He
reported that he had been homeless in the past year. The nurse recorded in the
medical records that Mr Filose did not raise any concerns and he engaged well.
18. On 15 February, a healthcare assistant completed Mr Filose’s second reception
screening. She reviewed his family medical history and recorded that there were no
concerns.
19. On 17 February, Mr Filose declined assistance with GP practice registration on
release. It is recorded in his medical records that there was no requirement for him
to have regular appointments with primary care staff while in prison.
20. On 19 February, Mr Filose’s Prison Offender Manager (POM) introduced himself to
Mr Filose and told him how to contact him.
21. On 20 February, Mr Filose had a blood test to check his blood sugar levels as he
reported that he used to have glucose tablets for low sugar levels. The results came
back as normal with no further action required.
22. On 4 March, prisoners raised concerns to staff regarding unusual behaviour from
Mr Filose. They reported that he was making strange noises at night and talking to
himself. Staff referred him to the mental health team.
23. On 20 March, a nurse saw Mr Filose for a mental health assessment. He said he
did not want to engage, and the nurse recorded that she had no reason to doubt his
capacity. Mr Filose reported that he was going to be homeless on release and did
not want any support or involvement from support services. The nurse offered
information around local support services for homeless people, a referral to NHS
Reconnect (a care after custody service that seeks to improve the continuity of care
of people leaving prison with an identified health need) and community mental
health services, but Mr Filose declined.
24. On 27 March, following a multi-disciplinary team meeting, Mr Filose was discharged
from the mental health team’s caseload. There were no identified needs for
secondary mental health services, and he did not want to engage.
25. A resettlement officer facilitated a video link meeting with Mr Filose and his
Community Offender Manager (COM). He told them that he did not consent to
housing referrals. The COM tried to explain that they needed his consent to share
information with the local authority, but he was adamant that he would not engage.
It is recorded that Mr Filose became verbally abusive to the COM and was spitting
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on the floor as he left the room. The COM told us that she did not consequently
complete any accommodation referrals for Mr Filose.
26. On 31 March, the COM completed an Offender Assessment System (OASys) risk
and needs report for Mr Filose. She noted that a Duty to Refer (a referral to the
local authority under the legal duty to refer those at risk of homelessness) and
Commissioned Rehabilitative Services (CRS) referral for housing were completed
prior to Mr Filose’s last release. The COM assessed that Mr Filose's refusal to
accept the support on offer during this sentence had made him wilfully homeless.
Release from HMP Winchester
27. On 2 April, Mr Filose was released from HMP Winchester. A nurse saw him prior to
release. She recorded that he was fit and well and did not raise any concerns
regarding his health.
28. Mr Filose attended his induction meeting with the COM. She went through his
licence conditions with him. Mr Filose signed the induction paperwork, where he
ticked his accommodation status as ‘friends/family (transient) / rough sleeping’. His
next appointment for assessment and planning was scheduled for 16 April.
29. On 7 April, Mr Filose’s cousin contacted the COM, wanting to get an important
message to Mr Filose about his mother. The COM texted Mr Filose and asked him
to call her.
30. On 8 April, the COM texted Mr Filose again and gave him his cousin’s phone
number.
Circumstances of Mr Filose’s death
31. On 10 April, the COM was informed by the police that Mr Filose had been found
dead in an abandoned car that he had been living in on 7 April.
Post-mortem report
32. The post-mortem report concluded that Mr Filose died of peritonitis, caused by
small bowel perforation. Bronchopneumonia contributed to, but did not cause, his
death.
Support for staff
33. When we contacted the POM as part of this investigation, he told us that he had not
been informed of Mr Filose’s death and so had not received any support.
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Findings
Clinical findings
34. The clinical reviewer concluded that the care Mr Filose received in the lead up to his
release from Winchester was not of the required standard. It was therefore not
equivalent to that which would have been received in the wider community.
35. The clinical reviewer found that there was an expectation amongst healthcare staff
that Mr Filose would self-refer to social support services such as NHS Reconnect.
Due to the concerns raised about Mr Filose’s mental health and behaviour, the
clinical reviewer questioned whether it was reasonable to expect Mr Filose to
engage with these services without support from healthcare staff.
36. The clinical reviewer found that there was no documented evidence that a Mental
Capacity Act assessment took place and Mr Filose was presumed to have had full
mental capacity. However, he found that the medical records documented subtle
features of deteriorating mental health and as such it would have been reasonable
to escalate these concerns for an in-depth assessment. This may have allowed a
more reliable judgment to have been made regarding Mr Filose’s ability to make
informed decisions about his health and welfare, including his ability to decline a
referral to social support services on release. We therefore make the following
recommendation:
The Head of Healthcare at Winchester should ensure that when an individual
exhibits impaired cognition, mental distress, confusion or unusual behaviour,
a formal Mental Capacity Act assessment is completed and documented, with
evidence of best-interest decision-making if capacity is lacking.
37. The clinical reviewer also made a further three recommendations. As they were not
directly relevant to Mr Filose's death we do not repeat them here, but the Head of
Healthcare at Winchester will wish to address them.
Accommodation
38. The COM told us that she made a referral to Commissioned Rehabilitative Services
(CRS) and completed a Duty to Refer referral when Mr Filose was previously in
prison, but he would not engage with the local authority or sign to give consent to
share his details. She said he attended one appointment with CRS and then
refused to engage. The COM discussed housing referrals with Mr Filose during this
prison sentence, but he remained adamant that he would not consent to them and
did not want any support with housing. The COM therefore did not submit further
referrals, and Mr Filose was released homeless.
39. The Head of Southampton, Eastleigh and New Forest Probation Delivery Unit
(PDU) told us that if probation practitioners have concerns regarding someone’s
mental capacity, they can escalate it to Adult Safeguarding in the local authority and
ask for a capacity assessment. However, the COM did not have access to Mr
Filose’s medical records and there was no indication that she was aware of his
behaviour in prison. Therefore, she did not have reason to doubt his capacity to
decline accommodation support and did not request an assessment.
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Governor to note
40. When we contacted the POM on 24 April, he was unaware that Mr Filose had died.
He had not been offered any support following Mr Filose’s death. We bring this to
the Governor at Winchester’s attention as it is important that all staff are informed
and offered support in advance of an investigation.
Adrian Usher
Prisons and Probation Ombudsman April 2026
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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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