Roberto Paguyo

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Independent investigation
A report by the Prisons and Probation Ombudsman
into the death of
Mr Roberto Paguyo, a prisoner
at HMP Wormwood Scrubs,
on 29 November 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
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© 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
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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 January 2023, Mr Roberto Paguyo was sentenced to six years and six months
imprisonment for sexual offences. He died of infective exacerbation of idiopathic
pulmonary fibrosis (progressive lung disease) on 29 November 2024, at HMP
Wormwood Scrubs. He was 60 years old. We offer our condolences to Mr Paguyo’s
family and friends.
4. The Ombudsman’s office wrote to Mr Paguyo’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
had no questions but asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer to review Mr
Paguyo’s clinical care at Wormwood Scrubs.
6. The clinical reviewer concluded that the clinical care Mr Paguyo received at
Wormwood Scrubs was of a good standard and equivalent to what he could have
expected to receive in the community. The clinical reviewer made recommendations
not related to Mr Paguyo’s death that the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Paguyo’s
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS and Practice Plus Group did not find any factual inaccuracies.
10. At the inquest held on 18 August 2025, the coroner concluded that Mr Roberto
Paguyo died of natural causes.
Adrian Usher May 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
OFFICIAL - FOR PUBLIC RELEASE