Simon Gerrard

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Independent investigation into
the death of Mr Simon Gerrard,
a prisoner at HMP Isle of Wight,
on 19 June 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, 2026
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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 September 2023, Mr Simon Gerrard was sentenced to 14 years in prison for
sexual offences. He died of bladder cancer on 19 June 2024, at HMP Isle of
Wight. He was 54 years old. We offer our condolences to Mr Gerrard’s family and
friends.
4. The Ombudsman’s office wrote to Mr Gerrard’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. The PPO investigator investigated the non-clinical issues relating to Mr Gerrard’s
care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Mr
Gerrard’s clinical care at HMP Isle of Wight.
7. The clinical reviewer concluded that the clinical care Mr Gerrard received at Isle of
Wight was of a good standard and equivalent to that which he could have
expected to receive in the community.
8. However, he found that Mr Gerrard was transferred from HMP Liverpool to Isle of
Wight while under active investigation for blood in his urine. Information about this
was not passed to the healthcare team at Isle of Wight and a referral was not
made by Isle of Wight until a month later. The clinical reviewer considered it
unlikely that this delay affected the outcome but that the poor information sharing
should be addressed. We recommend:
The Head of Healthcare at HMP Liverpool should ensure that when a
prisoner is awaiting or undergoing investigations at hospital:
• staff should consider the use of medical hold and record their decision;
and
• if medical hold is not considered appropriate and a transfer goes ahead,
staff should handover details of the outstanding referrals/ongoing
investigations to the receiving prison.
Prisons and Probation Ombudsman 1
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9. We shared our initial report with HMPPS and Spectrum Community Health CIC.
They found no factual inaccuracies. Spectrum Community Health CIC provided an
action plan which is annexed to this report.
Adrian Usher March 2025
Prisons and Probation Ombudsman
Inquest
At the inquest, held on 29 December 2025, the Coroner concluded that Mr Gerrard died
from natural causes.
2 Prisons and Probation Ombudsman
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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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