Sorin Fodor

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Independent investigation into
the death of Mr Sorin Fodor,
a prisoner at HMP Bedford,
on 4 April 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
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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 27 January 2025, Mr Sorin Fodor was remanded to HMP Bedford for weapons
offences and breach of bail.
4. Mr Fodor died in hospital on 4 April 2025, having spent nearly two months as an
inpatient. His cause of death was multi-organ failure resulting from a surgically
treated duodenal (small intestine) perforation. He was 57 years old. We offer our
condolences to Mr Fodor’s family and friends.
5. The Ombudsman’s office attempted to contact Mr Fodor’s mother, via a telephone
number provided by the Romanian Consulate. The number was not in service and
no other contact details were available.
6. NHS England commissioned an independent clinical reviewer to review the clinical
care Mr Fodor received at Bedford. The clinical reviewer’s report is attached as
Annex 1. The clinical reviewer concluded that the clinical care Mr Fodor received at
Bedford was of a reasonable standard and equivalent to that which he could expect
to have received in the community.
7. The PPO investigator investigated the non-clinical issues relating to Mr Fodor’s
care. We did not find any non-clinical issues of concern.
8. We shared the initial report with HM Prison and Probation Service. They did not
identify any factual inaccuracies.
9. The inquest into Mr Fodor’s death concluded on 24 September 2025, and returned
a verdict of natural causes.
Adrian Usher October 2025
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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