John Stafford

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr John Stafford,
a prisoner at HMP/YOI Hollesley
Bay, on 25 September 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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© 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. On 9 December 2010, Mr John Stafford received an indeterminate sentence for
public protection for sexual offences and received a minimum tariff of four years and
245 days. He died from a brain haemorrhage on 25 September 2024, while a
prisoner at HMP Hollesley Bay. He was 60 years old. We offer our condolences to
Mr Stafford’s family and friends.
4. The Ombudsman’s office wrote to Mr Stafford’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
Stafford’s next of kin had no questions but asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer to review Mr
Stafford’s clinical care at Hollesley Bay.
6. The clinical reviewer concluded that the clinical care Mr Stafford received at
Hollesley Bay was of a good standard and equivalent to what he could have
expected to receive in the community. The clinical reviewer made no
recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Stafford’s
care. We identified no significant non-clinical concerns.
8. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS),
Practice Plus Group pointed a factual inaccuracy in the clinical reviewer’s report,
and this has been amended accordingly.
10. Mr Stafford’s family received a copy of the initial report. They did not make any
comments.
11. At the inquest held on 13 August 2025, the coroner concluded that Mr John Peter
Stafford died of natural causes.
Adrian Usher June 2025
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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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
OFFICIAL - FOR PUBLIC RELEASE