Susan Simpson

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Independent investigation into
the death of Ms Susan Simpson,
a prisoner at HMP Downview,
on 29 June 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. On 4 February 2022, Ms Susan Simpson was sentenced to seven years in prison
for cruelty or neglect of children.
4. Ms Simpson died of oesophageal cancer (cancer of the food pipe) with liver
metastasis (cancerous tumours that have spread to the liver from another part of
the body) while a prisoner at HMP Downview. She was 55 years old. We offer our
condolences to Ms Simpson’s family and friends.
5. The Ombudsman Office wrote to Ms Simpson’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Ms Simpson’s family
asked for a copy of our report.
6. NHS England commissioned an independent clinical reviewer to review Ms
Simpson’s clinical care at Downview.
7. The clinical reviewer concluded that the clinical care Ms Simpson received at
Downview was of a good standard and at least equivalent to what she could have
expected to receive in the community.
8. Ms Simpson was diagnosed with an aggressive primary cancer which progressed
quickly. Her prognosis was poor. The clinical reviewer did not identify any obvious
deficiencies in the care she received at Downview and identified areas of good
practice. He did not make any recommendations.
9. The PPO investigator investigated the non-clinical issues relating to Ms Simpson’s
care.
10. We did not find any non-clinical issues of concern. We make no recommendations.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one factual inaccuracy, and this report has been amended
accordingly.
12. Ms Simpson’s family received a copy of the initial report. They did not make any
comments.
Adrian Usher December 2024
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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Inquests
13. At the inquest held on 19 August 2025, the coroner concluded Ms Simpson 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
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