John Rigby

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Independent investigation into
the death of Mr John Rigby,
a prisoner at HMP Wymott, on
17 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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© Crown copyright, 2025
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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 April 2023, Mr John Rigby was sentenced to seven years imprisonment for
sexual offences. He died of congestive cardiac failure (the heart does not pump
blood sufficiently well) on 17 December 2023, in hospital, while a prisoner at HMP
Wymott. He also had coronary artery disease (which also causes reduced blood
flow) and malignancy (cancer from an unidentified source) which did not cause but
contributed to his death. He was 76 years old. We offer our condolences to Mr
Rigby’s family and friends.
4. The Ombudsman’s office contacted Mr Rigby’s son and stepdaughter 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 Rigby’s
care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Mr Rigby’s
clinical care at HMP Wymott.
7. The clinical reviewer concluded that the clinical care Mr Rigby received at HMP
Wymott was variable, with some elements of care which were equivalent to that
which he could have expected to receive in the community and other elements
which were not. We make the following recommendations related to the clinical care
Mr Rigby received:
• The Head of Healthcare should ensure that prisoners with ongoing
treatment needs are identified and referred back into relevant specialist
services to ensure that continuity of healthcare is maintained.
• The Head of Healthcare should ensure that unregistered healthcare staff
appropriately escalate changes in a prisoner’s weight to registered
healthcare staff.
• The Head of Healthcare should investigate why the reason for Mr Rigby’s
GP appointment on 1 December 2023 was not included on the appointment
ledger and take appropriate action.
• The Head of Healthcare should ensure that prisoners with complex care
needs are added to the multi-disciplinary team caseload.
Prisons and Probation Ombudsman 1
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8. The clinical reviewer also made other recommendations not related to Mr Rigby’s
death that the Head of Healthcare will wish to address.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS and the healthcare provider, Greater Manchester Mental Health NHS
Foundation Trust pointed out a factual inaccuracy within the clinical review report,
which has been amended accordingly.
Adrian Usher
Prisons and Probation Ombudsman June 2024
Inquest
At the inquest, held on 8 October 2024, the Coroner concluded that Mr Rigby 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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