Ronald Cole

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Independent investigation into
the death of Mr Ronald Cole
a prisoner at HMP Full Sutton,
on 27 May 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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OFFICIAL - FOR PUBLIC RELEASE
© 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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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 30 October 1991, Mr Ronald Cole was sentenced to life in prison for murder. On
27 May 2025, while a prisoner at HMP Full Sutton, he died from community
acquired pneumonia, caused by chronic obstructive pulmonary disease (COPD).
This was contributed to but not caused by: heart failure, pulmonary hypertension
and chronic kidney disease stage 3-4. He was 78 years old. We offer our
condolences to Mr Cole’s family and friends.
4. The Ombudsman’s office contacted Mr Cole’s next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not
respond.
5. NHS England commissioned an independent clinical reviewer, to review Mr Cole’s
clinical care at HMP Full Sutton. The clinical review is attached as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Cole received at Full Sutton
was of a reasonable standard and partially equivalent to that which he could have
expected to receive in the community. She found that Mr Cole received healthcare
access in a timely manner, despite his repeated refusal to move to the healthcare
unit. However, she was concerned that healthcare staff did not comply with the
prison medical emergency response codes and call a code blue (indicating a
prisoner is having breathing difficulties) on 22 May, despite the incident meeting the
criteria. She assessed that Mr Cole’s medical care was not affected as the
ambulance arrived within 20 minutes.
7. The PPO investigator investigated the non-clinical issues relating to Mr Cole’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 did not find any factual inaccuracies.
10. At an inquest held on 23 January 2026, the Coroner concluded that Mr Cole died of
natural causes.
Adrian Usher November 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