Stephen Gedge

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Independent investigation into
the death of Mr Stephen Gedge,
a prisoner at HMP Onley,
on 9 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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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 5 July 2024, Mr Stephen Gedge was sentenced to 20 months in prison for
stalking. He was initially remanded to HMP Wormwood Scrubs and then, on 11
July, transferred to HMP Onley.
4. Mr Gedge died of metastatic oesophageal cancer (cancer that started in the food
pipe and spreads to other parts of the body) on 9 September 2024. He was 48
years old. We offer our condolences to Mr Gedge’s family and friends.
5. NHS England commissioned an independent clinical reviewer to review the clinical
care Mr Gedge received at Onley. The clinical reviewer concluded that the clinical
care Mr Gedge received at Onley was of a reasonable standard and was equivalent
to that which he could expect to receive in the community.
6. The Ombudsman’s office contacted to Mr Gedge’s mother, his nominated next of
kin, to explain the investigation and to ask if she had any matters she wanted us to
consider. She asked when Mr Gedge was diagnosed with cancer and about the
care he received at HMP Wormwood Scrubs. These questions are addressed in the
clinical review.
7. The PPO investigator investigated the non-clinical issues relating to Mr Gedge’s
care. We did not find any non-clinical issues of concern. We make no
recommendations.
8. The inquest into Mr Gedge’s death concluded on 25 September 2024 and returned
a verdict of natural causes.
Adrian Usher July 2025
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
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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