Steven Rylands

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Independent investigation into
the death of Mr Steven Rylands,
a prisoner at HMP Frankland, on
9 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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OFFICIAL - FOR PUBLIC RELEASE
© 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 March 1987, Mr Steven Rylands was sentenced to life imprisonment for
kidnapping and other offences. He died of a combination of sepsis (a life-
threatening overreaction of the body to an infection) resulting from leg ulcers and
ketoacidosis (severe lack of insulin) which was caused by a complication of
diabetes. He died on 9 June 2024 at HMP Frankland. He was 64 years old. We
offer our condolences to Mr Rylands’ family and friends.
4. The Ombudsman’s office wrote to Mr Rylands’ 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 Rylands’
clinical care at Frankland.
6. The clinical reviewer concluded that the clinical care Mr Rylands received at
Frankland was of a high standard and equivalent to that which he could have
expected to receive in the community. She found that Mr Rylands received
excellent individualised end of life care planning. The clinical reviewer made no
recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Rylands’
care. We did not find any non-clinical issues of concern. We make no
recommendations.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Adrian Usher November 2024
Prisons and Probation Ombudsman
Inquest
The inquest hearing was held on 7 February 2025. The Coroner concluded that Mr
Rylands died of natural causes.
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