Simon Penton

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Independent investigation into
the death of Mr Simon Penton,
a prisoner at HMP Warren Hill,
on 14 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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OFFICIAL - FOR PUBLIC RELEASE
© 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 1 April 2014, Mr Simon Penton was sentenced to life imprisonment for
manslaughter. On 17 February 2021, he was transferred to HMP Warren Hill.
4. Mr Penton died on 14 November 2024, due to squamous cell carcinoma of the
tonsil (a type of cancer in the tonsil's lining cells), with ischaemic heart disease
(reduced blood supply to the heart) as a contributing factor. He was 54 years old.
We offer our condolences to Mr Penton’s family and friends.
5. The Ombudsman’s office contacted to Mr Penton’s partner, his nominated next of
kin, to explain the investigation and to ask if she had any matters she wanted us to
consider. She did not respond.
6. NHS England commissioned an independent clinical reviewer, to review the clinical
care Mr Penton received at Warren Hill. The clinical reviewer’s report is attached as
Annex 1. The clinical reviewer concluded that the clinical care Mr Penton received
at Warren Hill was of a reasonable standard and was equivalent to that which he
would have received in the community. He found that healthcare staff managed Mr
Penton with compassion and care.
7. The PPO investigator investigated the non-clinical issues relating to Mr Penton’s
care. We did not find any non-clinical issues of concern.
8. The inquest into Mr Penton’s death concluded on 3 October 2025, returning a
verdict of natural causes.
Adrian Usher July 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