Paul Edmunds

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Independent investigation into
the death of Mr Paul Edmunds,
a prisoner at HMP Long Lartin,
on 22 January 2025
A report by the Prisons and Probation Ombudsman
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© Crown copyright, 2025
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Prisons and Probation Ombudsman
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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 December 2017, Mr Paul Edmunds was sentenced to 30 years imprisonment for
firearms offences. He died in hospital of bowel cancer on 22 January 2025, while a
prisoner at HMP Long Lartin. He was 73 years old. We offer our condolences to Mr
Edmunds’ family and friends.
4. The Ombudsman’s office wrote to Mr Edmunds’ son to explain the investigation and
to ask if he had any matters he wanted us to consider. He did not respond to our
letter.
5. NHS England commissioned an independent clinical reviewer to review Mr
Edmunds’ clinical care at HMP Long Lartin.
6. The clinical reviewer concluded that the clinical care Mr Edmunds received at Long
Lartin was of a good standard and equivalent to that which he could have expected
to receive in the community. She made two recommendations not related to Mr
Edmunds’ death that the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Edmunds’
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. HMPPS found no factual inaccuracies. Practice Plus Group
pointed out some factual inaccuracies in the clinical review. This has been
amended and has been reattached as an annex.
10. The inquest, held on 22 May 2025, concluded that Mr Edmunds died from natural
causes.
Adrian Usher July 2025
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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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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