Tony King

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Independent investigation into
the death of Mr Tony King,
a prisoner at HMP Swaleside,
on 18 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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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 23 June 2023, Mr Tony King was sentence to life for murder. He was initially
remanded at HMP Lewes and then, on 3 August 2023, transferred to HMP
Swaleside.
4. Mr King died of sudden cardiac death due to chronic myocardial scarring (a
condition where the heart muscle is scarred due to injury or disease) on 18 June
2024, at Swaleside. He was 61 years old. We offer our condolences to Mr King’s
family and friends.
5. The Ombudsman’s office contacted to Mr King’s friend, his nominated next of kin, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She had no questions.
6. The PPO investigator investigated the non-clinical issues relating to Mr King’s care.
We did not find any non-clinical issues of concern.
7. NHS England commissioned an independent clinical reviewer to review the clinical
care Mr King received at Swaleside.
8. The clinical reviewer concluded that the majority of the clinical care that Mr King
received at Swaleside was of a good standard and was equivalent to that which he
would have received in the community. However, on 17 June 2024, the day before
he died, Mr King presented with chest pains. The clinical reviewer found that he
should have been reviewed by a doctor and referred to hospital. We make the
following recommendations:
The Head of Healthcare should ensure that all staff are trained in the local
operating procedure ‘Management of Acute Chest Pain’ and understand how
to refer to the GP and local hospital.
The Head of Healthcare should review the Local Operating Procedure to
include the management of patients that have chest pain that decline clinical
observations.
9. The inquest into Mr King’s death concluded on 4 June 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