George Stephenson

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Independent investigation into
the death of Mr George
Stephenson,
a prisoner at HMP Full Sutton,
on 20 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, 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 October 1987, Mr George Stephenson was sentenced to life imprisonment for
murder, with a minimum tariff of 35 years. He died of heart failure and ischaemic
heart disease on 20 April 2025, while a prisoner at HMP Full Sutton. He was 73
years old. We offer our condolences to those who knew him.
4. NHS England commissioned an independent clinical reviewer, to review Mr
Stephenson’s clinical care at HMP Full Sutton. The clinical reviewer’s report is
attached as Annex 1.
5. The clinical reviewer concluded that the clinical care Mr Stephenson received at Full
Sutton was of a good standard and equivalent to what he could have expected to
receive in the community. She found that Mr Stephenson’s care plans were
detailed, appropriately initiated and updated by healthcare staff. She found several
examples of kind, respectful and compassionate interactions between healthcare
staff and Mr Stephenson. She made no recommendations.
6. The PPO investigator investigated the non-clinical issues relating to Mr
Stephenson’s care.
7. 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
Prisons and Probation Ombudsman August 2025
Inquest
9. At the inquest held on 19 September 2025, the Coroner concluded that Mr
Stephenson died of natural causes.
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