Ricardo Cotteral

OFFICIAL - FOR PUBLIC RELEASE
,
Independent investigation into
the death of Mr Ricardo Cotteral,
a prisoner at HMP Sudbury,
on 24 April 2022
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
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.
If my office is to best assist HM Prison and Probation Service 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.
Mr Ricardo Cotteral was murdered by four men in Nottingham City Centre on 24 April
2022, while released on overnight temporary licence from HMP Sudbury. He died of a stab
wound to the chest. He was 33 years old. I offer my condolences to Mr Cotteral’s family
and friends.
On 25 July 2023, the four men were found guilty of Mr Cotteral’s murder and later
sentenced to life in prison.
Prison managers assessed Mr Cotteral as suitable for release on temporary licence
(ROTL) on 9 October 2021. He had been released on day and overnight ROTL many
times before April 2022. However, the investigation found that Sudbury’s process for
granting ROTL were sub-optimal and did not allow for all relevant information to be
considered.
Although the clinical reviewer considered that Mr Cotteral received a satisfactory standard
of healthcare at HMP Sudbury, she was concerned that healthcare staff were not involved
in the ROTL risk assessment process.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman January 2025
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 20 May 2020, Mr Ricardo Cotteral was remanded to HMP Nottingham, charged
with possession with intent to supply a Class A drug. On 20 November, he was
sentenced to three and a half years in prison.
2. On 18 August 2021, Mr Cotteral was transferred to HMP Sudbury.
3. On 15 October, the Head of the Offender Management Unit (OMU) authorised Mr
Cotteral’s application for release on temporary licence (ROTL, which allows
prisoners periods in the community for work or to build family relationships). Mr
Cotteral began periods of ROTL soon after.
4. On 18 January 2022, Mr Cotteral made a formal complaint that he could not start
work in the community as his prison offender manager (POM) did not support his
ROTL. The next day, the Head of OMU and a prison manager approved ROTL for
paid work. Contrary to guidance, Mr Cotteral’s POM responded to the complaint. Mr
Cotteral appealed and was allocated a new POM.
5. Between 29 and 31 March, staff submitted intelligence reports that Mr Cotteral had
access to a mobile phone and was suspected of being involved in the prison’s illicit
drug market. However, there is no evidence that staff took any action, and the
details were not recorded in Mr Cotteral’s prison record.
6. On 20 April, prison staff released Mr Cotteral on ROTL until 24 April.
7. At 1.57am on 24 April, a group of men approached Mr Cotteral outside a nightclub
in Nottingham Town Centre and stabbed him. At 2.43am, paramedics at the scene
pronounced that Mr Cotteral had died.
8. On 25 July 2023, four men were found guilty of Mr Cotteral’s murder. They were
sentenced to life in prison on 7 September.
Findings
9. Processes for granting ROTL at Sudbury were not as robust as they should have
been, and information related to Mr Cotteral’s suspected involvement in illicit activity
in the prison was not considered. However, Mr Cotteral had been released on
ROTL many times before 20 April, including almost every day in April, and there
was no particular intelligence to suggest that his life was at risk in the community.
10. It is not possible for us to make a firm judgement on the appropriateness, or
otherwise, of Mr Cotteral’s release on ROTL on 20 April because the correct
processes were not followed. It is not possible, in the context of his having been
released over one hundred times previously, to draw direct causal link between the
decision making (or lack thereof) and Mr Cotteral’s death.
11. The clinical reviewer considered that the standard of healthcare that Mr Cotteral
received at HMP Sudbury was equivalent to that which he could have expected to
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
receive in the community. However, the clinical reviewer was concerned that
healthcare staff did not contribute to Mr Cotteral’s ROTL risk assessment.
12. Contrary to policy, Mr Cotteral’s POM responded to a complaint that Mr Cotteral
had made about him. It was not appropriate that the individual tasked with
responding to the complaint was also the subject of the complaint.
Recommendations
• The Governor should ensure that:
• all ROTL board reviews and decisions are made in or following a discussion or
meeting between the board members and any other relevant individuals;
• an urgent ROTL board review takes place when there is evidence to suggest an
increased risk;
• staff act on and share all information with OMU that indicates that ROTL may no
longer be appropriate due to increased risk; and
• staff put negative entries and security information on the prison’s case
management system so they can be identified in pre-ROTL checks and
considered by the authorising manager.
• The Ministry of Justice’s Release Policy Team should amend the ROTL Policy
Framework to include that healthcare staff are consulted when there is information
available to indicate concerns about a prisoners ability to comply with ROTL.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
13. HMPPS notified us of Mr Cotteral’s death on 24 April 2022.
14. The investigator issued notices to staff and prisoners at HMP Sudbury, informing
them of the investigation and asking anyone with relevant information to contact. No
one responded.
15. The investigator obtained copies of relevant extracts from Mr Cotteral’s prison and
medical records.
16. The investigator interviewed seven members of staff at HMP Sudbury between 9
and 21 September 2023.
17. NHS England commissioned a clinical reviewer to review Mr Cotteral’s clinical care
at the prison. The investigator and clinical reviewer conducted joint interviews with
healthcare staff.
18. We suspended our investigation between November 2022 and February 2023 while
the police investigated the circumstances of Mr Cotteral’s death, and his murder
trial concluded. The investigator remained in regular contact with the police.
19. We suspended our investigation again between May and July 2023 while we waited
for NHS England’s clinical review.
20. We informed HM Coroner for Nottingham City of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
21. The Ombudsman’s office contacted Mr Cotteral’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Cotteral’s family
wanted to know:
• the conditions of his release of temporary licence; and
• if someone checked that he was abiding by them.
We have addressed these concerns in this report.
22. Mr Cotteral’s family received a copy of the initial report. They did not raise any
further issues, or comment on the factual accuracy of the report.
23. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Sudbury
24. HMP Sudbury is an open prison. Sudbury caters for prisoners in the latter stages of
their sentence and specialises in rehabilitation and resettlement in preparation for
release into the community. A number of prisoners are released each day on
licence to help with their resettlement.
25. Practice Plus Group provides primary and mental health services. South
Staffordshire and Shropshire Healthcare NHS Foundation Trust provides drug and
substance misuse services.
HM Inspectorate of Prisons
26. The most recent full inspection of HMP Sudbury was in August 2023. Inspectors
found that over 40% of the population had committed offences related to drug
supply, with around a third connected to organised crime gangs. Despite having
had a full-time police intelligence officer for several months, not enough had been
done to reduce the supply of, and the demand for, illicit drugs.
27. Inspectors found that there was a wide range of creative opportunities available to
prisoners to help build and maintain family ties, and good use of day and overnight
ROTL.
Independent Monitoring Board
28. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 31 May 2023, the IMB reported
that preventing the supply illicit drugs into the prison was a continuous challenge.
They also noted that a total of 229 prisoners had been transferred back to closed
conditions.
Previous deaths at HMP Sudbury
29. Mr Cotteral was the fifth prisoner to die while a prisoner at Sudbury since April
2019. Two of the previous deaths were from natural causes and two were drug-
related. There were no similarities between the findings of this investigation and
those of the previous deaths we investigated.
Release on temporary licence (ROTL)
30. All prisoners, except those who fall within a defined group excluded from applying
for ROTL or those subject to Restricted ROTL conditions, may apply for temporary
release under a special purpose licence at any point during their sentence. ROTL
facilitates the rehabilitation of offenders by helping to prepare them for resettlement
in the community once they are released. This includes finding work and rebuilding
family ties. ROTL is mostly used in open prisons, but closed prisons can release
eligible prisoners if they have suitable resourcing and infrastructure in place. ROTL
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
can be granted for day-long periods (to attend work, for example) or for longer
periods.
31. The decision to allow ROTL must always be considered by means of a rigorous risk
assessment. A prison offender manager (POM) completes the assessment and a
ROTL board should meet to discuss it and make decisions. The ROTL board is
often chaired by a custodial manager (CM) and should include the POM and any
other relevant member of staff. The board reviews the risk assessment and
recommends whether they deem ROTL appropriate, as well as outlining any non-
standard licence conditions and/or specific monitoring measures needed. A senior
manager then reviews the risk assessment and if in agreement with the board,
authorises the ROTL. A ROTL board risk assessment should be reviewed every six
months, or earlier, if there is information or intelligence to indicate an increased risk.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
32. On 20 May 2020, Mr Ricardo Cotteral was remanded to HMP Nottingham, charged
with possession with intent to supply a Class A drug. On 20 November, he was
sentenced to three and a half years in prison and returned to Nottingham.
33. On 30 November, Mr Cotteral was moved to HMP Ranby. Over the next eight
months, he progressed through his sentence and achieved enhanced (trusted)
prisoner status.
HMP Sudbury
2021
34. On 18 August 2021, Mr Cotteral was transferred to HMP Sudbury as part of his
sentence progression.
35. On 25 August, a mental health nurse saw Mr Cotteral for a mental health
assessment. He noted that Mr Cotteral reported a history of anxiety, attention deficit
hyperactivity disorder (ADHD) and autism.
36. On 9 September, a community learning disability nurse reviewed Mr Cotteral and
offered him ongoing support.
37. On 9 October 2021, a Custodial Manager (CM) recorded that he had chaired Mr
Cotteral’s initial Release on Temporary Licence (ROTL) risk assessment board. The
ROTL board document indicates that several members of staff, including Mr
Cotteral’s prison offender manager (POM), attended. However, during staff
interviews, it became apparent that the ROTL process at the time consisted of the
POM completing the form and sending it to the chair for review, rather than a
meeting of staff to discuss the application. The POM recorded that Mr Cotteral had
enhanced prisoner status and had received positive feedback for his work in the
prison’s recycling department. The CM noted that the board recommended that Mr
Cotteral should start with resettlement day release at his grandmother’s address.
They did not agree to resettlement overnight release as his family were concerned
about him staying with his grandmother. There was no intelligence to suggest that
Mr Cotteral’s life was at imminent risk in the community.
38. On 15 October, the Head of the prison’s Offender Management Unit (OMU)
reviewed Mr Cotteral’s ROTL board risk assessment and authorised resettlement
day release.
39. On 8 November, a CM reviewed the revised ROTL board document the POM had
sent her. Mr Cotteral’s family had changed their minds about overnight
resettlement. The POM noted that security staff suspected Mr Cotteral had access
to a mobile phone and was involved in the prison’s illicit drug trade. He concluded
that he did not support ROTL as he felt that Mr Cotteral’s risk could not be managed
in the community. The CM noted that she had spoken to the prison’s Head of
Security and Mr Cotteral’s community probation officer who supported resettlement
overnight release at his grandmother’s address. Overnight ROTL was subsequently
approved.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
40. Between 16 and 19 December, staff made several negative entries about Mr
Cotteral’s behaviour in his prison file. As a result, on 22 December, the POM
suspended Mr Cotteral’s ROTL for the Christmas period.
41. At 9.58am on 23 December, a nurse visited Mr Cotteral for an urgent review
because he presented as anxious and agitated. She noted that he had lost his
ROTL over Christmas and that she would tell the Head of OMU about his autism
diagnosis. Later that day, the Head chaired a multidisciplinary team meeting and
went through the negative entries with Mr Cotteral. He noted that Mr Cotteral
attributed his behaviour to his autism and agreed to reinstate his ROTL.
42. On 31 December, Mr Cotteral received a job offer from Boots. He subsequently
submitted a ROTL application form.
2022
43. Between 2 and 16 January 2022, Mr Cotteral left the prison six times on day
release.
44. On 12 January, a business, community and engagement manager wrote to Mr
Cotteral telling him that she was going to withdraw his job offer as his POM did not
support his ROTL. Mr Cotteral made a formal complaint about his POM.
45. Senior prison managers concluded that Mr Cotteral was suitable for ROTL for paid
work. (Mr Cotteral left the prison on ROTL 118 times before his death. Most of his
ROTLs were on day release to attend work in the community but he also had
several overnight releases to help maintain family ties.)
46. Staff continued to record negative entries about Mr Cotteral’s behaviour. Including
that they suspected he was involved in trading illicit drugs at Sudbury.
47. On 25 January, and contrary to the Prisoner Complaints Policy Framework, the
POM replied in writing to Mr Cotteral’s complaint about him. At interview, he told us
that he did not want to respond because the complaint was about him, but a Senior
Probation Officer (SPO), who was his manager, did not want to respond to it. (The
SPO no longer works at Sudbury and was not interviewed as part of the
investigation.)
48. On 9 February, a mental health nurse recorded that he saw Mr Cotteral for a mental
health inreach review. He noted that Mr Cotteral was very distressed and not happy
with his POM, whom he said had rejected his ROTL.
49. On 10 February, the POM emailed the Head of OMU, outlining concerns that Mr
Cotteral’s ROTL had been reinstated, despite them agreeing that Mr Cotteral
needed to demonstrate improved behaviour first. The Head told the investigator that
he was on annual leave at the time and was not sure who decided to allow Mr
Cotteral to continue with his ROTL to work outside of the prison.
50. On 18 February, Mr Cotteral submitted another complaint, stating that he was not
happy with his POM’s response. He said that he was expecting the SPO to respond
and asked, “where is independent scrutiny?” The following week, the OMU hub
manager wrote to Mr Cotteral that the Head of OMU and the SPO would respond as
soon as possible.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
51. On 15 March, the Head of OMU wrote to Mr Cotteral, saying that they had
discussed his complaint and he hoped he was happy with the outcome. He also
confirmed that he had appointed him a new POM. At interview, the Head said that
he could not recollect the exact events, but remembered attending a meeting with
Mr Cotteral, the SPO, and the new POM to discuss his concerns.
52. Between 29 and 31 March, staff submitted intelligence reports indicating that Mr
Cotteral had access to a mobile phone and was mixing with another prisoner
suspected of involvement in the illicit drug trade. There is, however, no evidence
that staff took any action.
53. Mr Cotteral was released on ROTL to attend work almost every day in April.
54. On 19 April, a case administrator checked NOMIS for any negative entries or
intelligence to suggest an increase in risk before the duty manager signed off Mr
Cotteral’s licence. She did not identify information to cause concern (the intelligence
reports were not reflected on NOMIS and there is no evidence that the process
included her separately checking security intelligence.)
55. On 20 April, prison staff released Mr Cotteral on resettlement overnight release until
24 April. He stayed at his grandmother’s home and was subject to standard licence
conditions (including a requirement not to offend, to be of good behaviour, keep in
touch with his supervising probation officer and reside at an approved address).
Events of 24 April
56. At around 1.57am on 24 April, a group of men stabbed Mr Cotteral outside a
nightclub in Nottingham Town Centre. Mr Cotteral ran off down the street, but the
men chased after him and stabbed him multiple times.
57. At 2.43am, paramedics at the scene pronounced that Mr Cotteral had died. At
12.15pm, the police notified the prison.
Contact with Mr Cotteral’s family
58. The police had broken the news of Mr Cotteral’s death to his family and had
appointed a police family liaison officer. Mr Cotteral’s family had visited the place
where Mr Cotteral died.
59. At 2.30pm, the prison appointed an officer as family liaison officer (FLO)and an
Operational Support Grade (OSG) as his deputy. The FLO was not at work on 24
April and, because Mr Cotteral’s family had a police family liaison officer, a CM
agreed that he could start family liaison duties when he returned to work on 25
April.
60. At 12.15pm on 25 April, the FLO and a prison chaplain visited Mr Cotteral’s ex-
partner, who was Mr Cotteral’s named next of kin. They offered support and
explained the next steps.
61. On 27 April, the FLO, his deputy and a prison governor visited Mr Cotteral’s ex-
partner. Later that day, the governor and the deputy visited Mr Cotteral’s sister and
mother. At both visits, they offered their condolences and support.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
62. The FLO remained in contact with Mr Cotteral’s ex-partner. Mr Cotteral’s funeral
took place on 4 October and the prison contributed towards the cost, in line with
national policy.
Support for prisoners and staff
63. The prison posted notices informing other prisoners of Mr Cotteral’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Cotteral’s death.
Post-mortem report
64. The post-mortem report concluded that Mr Cotteral died of a stab wound to the
chest.
Events after Mr Cotteral’s death
65. On 25 July 2023, four men were found guilty of Mr Cotteral’s murder. On 7
September, they were sentenced to life in prison, with minimum terms to serve
ranging from 25 to 30 years. In court, the murder was described as a revenge
attack linked to a previous violent incident involving Mr Cotteral and the defendants.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
66. Mr Cotteral was murdered while on overnight ROTL from Sudbury. There was no
intelligence to suggest that his life was at risk in the community.
Release on Temporary Licence processes
67. Mr Cotteral had been released on day and overnight ROTL over 100 times since
arriving at Sudbury. Our investigation identified some short comings in the ROTL
process.
68. The ROTL Policy Framework states that a ROTL board must convene to make an
appropriate recommendation based on the information contained in the ROTL risk
assessment. This did not happen in Mr Cotteral’s case. The ROTL board did not
meet on 9 October and 8 November 2022. The POM told the investigator that, at
the time, the local procedure was for the POM to collate all the relevant information,
complete a risk assessment and send it to the chair of the ROTL board for review
and to make a decision about whether a prisoner should be released on temporary
licence. Staff should have met to discuss the potential risks and to minimise their
impact. This would have been particularly important on 8 November when he did
not support ROTL and his relationship with Mr Cotteral began to break down.
69. The ROTL policy states that it is essential that the ROTL board process is
supplemented by systems that ensure that significant changes in risk or offender
behaviour can lead to an urgent review of ROTL and to suspension where
necessary. While we appreciate that the POM held a meeting with Mr Cotteral and
several members of staff to discuss his complaint in March 2023, staff should have
held a ROTL board. The POM had raised valid concerns about Mr Cotteral’s ability
to comply with ROTL, and his concerns should have been discussed. It is also
possible that by changing his POM and not fully addressing the concerns that the
first POM raised, the prison effectively enabled Mr Cotteral to manipulate the
system to his advantage. Holding a board review with all the relevant stakeholders,
including the first POM, would have allowed for a systematic and fair assessment of
his risk.
70. We found weaknesses in the process for identifying relevant intelligence ahead
during the ROTL process. OMU staff responsible for running pre-ROTL checks did
not have sight of the intelligence reports staff had submitted about Mr Cotteral in the
early part of 2022.
71. There was no direct information that Mr Cotteral’s life was at risk in the community
and, indeed, he left the prison on ROTL almost every day in April to work and for at
least one other overnight stay that month. However, we do not think that the ROTL
approval processes at Sudbury are sufficiently robust. We make the following
recommendation:
The Governor should ensure that:
• all ROTL board reviews and decisions are made in or following a
discussion or meeting between the board members and any other relevant
individuals;
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
• an urgent ROTL board review takes place when there is evidence to
suggest an increased risk;
• staff act on and share all information with OMU that indicates that ROTL
may no longer be appropriate due to increased risk; and
• staff put negative entries and security information on the prison’s case
management system so they can be identified in pre-ROTL checks and
considered by the authorising manager.
Healthcare involvement in ROTL risk assessments
72. Mr Cotteral had autism and was supported by the mental health team at HMP
Sudbury. The clinical reviewer was therefore concerned that healthcare staff were
not involved in Mr Cotteral’s ROTL risk assessment.
73. The ROTL Policy Framework states that it is good practice that healthcare checks
are made before overnight releases to ensure that a prisoner’s needs are identified
and that they have access to any treatment they need during release. This did not
happen in Mr Cotteral’s case.
74. We contacted the Ministry of Justice’s Release Policy Team by email as part of our
investigation, to establish whether healthcare staff should be invited to contribute to
ROTL risk assessments. They said that the Policy Framework does not mandate
the involvement of healthcare staff in ROTL risk assessments but that they
expected consultation with healthcare staff where relevant.
75. We agree with the clinical reviewer that for a risk assessment to be holistic,
healthcare staff should contribute to the process. We make the following
recommendation:
The Ministry of Justice’s Release Policy Team should amend the ROTL Policy
Framework to include that healthcare staff are consulted when there is
information available to indicate concerns about a prisoners ability to comply
with ROTL.
Clinical care
76. The clinical reviewer considered that the standard of healthcare that Mr Cotteral
received at HMP Sudbury was equivalent to that which he could have expected in
the community.
Governor to note
77. The POM responded to a complaint that Mr Cotteral had made about his decision-
making. The Prisoner Complaints Policy Framework states that complaints must be
answered by someone who can provide an adequate and meaningful reply and is
not the focus of the complaint.
78. The Head of OMU told us that when a prisoner submitted a complaint about a
member of staff, their manager would normally respond, which was why it was sent
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
to a SPO to address. He added that it was likely that she allocated the complaint to
the POM as staff try to address complaints at the lowest level. However, the POM
told us that he felt the SPO did not want to respond to the complaint. Regardless of
the reason, it was not appropriate for the POM to respond.
79. By asking the POM to respond to Mr Cotteral’s complaint and by authorising Mr
Cotteral’s ROTL without a full discussion of his concerns, we consider that senior
prison and probation staff undermined his authority and expertise. The Governor
will want to ensure that staff address complaints from prisoners in line with the
Prisoner Complaints Policy Framework.
Inquest
80. At the inquest, which took place on 17 July 2024, the Coroner concluded that Mr
Cotteral died of unlawful killing.
12 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