Stephen Hopkins

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Independent investigation into
the death of
Mr Stephen Hopkins,
a prisoner at HMP Cardiff,
on 2 December 2023
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, 2025
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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 4 November 2022, Mr Stephen Hopkins was remanded into custody at HMP
Cardiff, charged with two counts of conspiracy to supply Class A drugs. He died of
septic shock on 2 December 2023 while still on remand. This was caused by an
anastomotic leak (a post-surgical complication) following rectal cancer surgery. He
was 59 years old. We offer our condolences to Mr Hopkins’ family and friends.
4. The Ombudsman’s office wrote to Mr Hopkins’ next of kin to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond to our letter.
5. Healthcare Inspectorate Wales commissioned an independent clinical reviewer to
review Mr Hopkins’ clinical care at HMP Cardiff.
6. The clinical reviewer concluded that the clinical care Mr Hopkins received at HMP
Cardiff was of a good standard and equivalent to that which he could have expected
to receive in the community. He found that Mr Hopkins had good quality healthcare
in managing his cancer diagnosis and substance misuse.
7. The clinical reviewer made recommendations not related to Mr Hopkins’ death that
the Head of Healthcare at HMP Cardiff will want to address.
8. The PPO investigator investigated the non-clinical issues relating to Mr Hopkins’
care. We did not identify any non-clinical concerns and make no recommendations.
9. However, the Governor should note that we were not provided with any staff
statements or evidence that a hot debrief took place. While the bed watch officers
worked at other prisons, it was HMP Cardiff’s responsibility to offer support to all
staff members involved in Mr Hopkins’ care.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. At an inquest held on 7 March 2025, the Coroner concluded that Mr Hopkins died of
natural causes.
Adrian Usher June 2024
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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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