Lionel Newbon

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Independent investigation into
the death of Mr Lionel Newbon,
a prisoner at HMP Frankland, on
9 November 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
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 1982, Mr Lionel Newbon was sentenced to life imprisonment for sexual offences.
He died of acute bronchopneumonia (inflammation of the lung tubes) caused by
carcinoma of the oesophagus (cancer of the tube that carries food from the mouth
to the stomach) on 9 November 2024 at HMP Frankland. He was 66 years old. We
offer our condolences to those who knew Mr Newbon.
4. The PPO investigator investigated the non-clinical issues relating to Mr Newbon’s
care. We did not find any non-clinical issues of concern.
5. NHS England commissioned an independent clinical reviewer to review Mr
Newbon’s clinical care at Frankland.
6. The clinical reviewer concluded that the clinical care Mr Newbon received at
Frankland was equivalent to that which he could have expected to receive in the
community. She found that Mr Newbon’s medical records contained evidence of
good, individualised end of life care planning.
7. However, the clinical reviewer found that healthcare staff were not clear about what
information could be shared with custodial staff about Mr Newbon’s DNACPR (Do
Not Attempt Cardiopulmonary Resuscitation) instruction form, as they perceived it
to be ‘medical in confidence’ information. She made one recommendation, which
we endorse and recast:
The Governor and the Head of Healthcare should review the disclosure of
DNACPR instructions to custodial staff. Custodial staff should be aware of
those who wish not to be resuscitated and have access to a DNACPR
instruction form (which can have confidential medical information redacted).
8. The initial report was shared with HM Prison and Probation Service (HMPPS) and
Spectrum CiC (healthcare provider). They pointed out one factual inaccuracy and
this report has been amended accordingly.
Adrian Usher June 2025
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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Inquest
The inquest hearing was held on 18 July 2025. The Coroner concluded that Mr Newbon
died of 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
OFFICIAL - FOR PUBLIC RELEASE