David Mears

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Independent investigation into
the death of Mr David Mears,
a prisoner at HMP Channings
Wood, on 17 August 2021
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
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Summary
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. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr David Mears died in hospital on 17 August 2021, while a prisoner at HMP
Channings Wood. He was 65 years old. The cause of Mr Mears’ death was
COVID-19 and diabetic foot. He also had underlying diabetes, asthma and heart
disease. I offer my condolences to Mr Mears’ family and friends.
4. Given the variable incubation period of COVID-19, we cannot say whether Mr
Mears caught the virus in prison or as an inpatient in hospital.
5. The clinical reviewer concluded that Mr Mears’ clinical care was not equivalent to
that he could have expected to receive in the community. Notably, there were no
formal care plans to manage his long-term health conditions and inadequate follow-
up when his blood sugar levels were raised. There was also a lack of clarity as to
the responsibility for mental capacity assessments and they were not timely, nor
recorded in sufficient detail. Full details of the findings are in the clinical reviewer’s
report.
6. We did not receive all the hospital escort documents. However, from the
information on those available, we consider that the use of restraints was not
justified, given Mr Mears was a wheelchair user who had been assessed as a low
risk of escape. It is of particular concern that they were used in spite of the
debilitation caused by intravenous treatment and surgery to amputate two toes.
7. There was a delay in notifying Mr Mears’ wife that he was seriously ill in hospital
and that he had contracted COVID-19.
Recommendations
• The Head of Healthcare should ensure that:
• formal care plans are in place to manage patients with chronic health
conditions; and
• healthcare staff record the details and outcome of assessments in patients’
medical records; and follow the protocols for escalating concerns or
deterioration.
• The Head of Healthcare should ensure that a formal mental capacity assessment is
promptly completed and fully documented when there are concerns that a prisoner
has declined medical advice or treatment.
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• The Governor should ensure that all staff undertaking and reviewing risk
assessments for prisoners admitted to hospital understand the legal position on the
use of restraints, that assessments fully take into account the prisoner’s health and
mobility and are based on the actual risk he presents at the time.
• The Governor should ensure that, in line with national policy, prisoners’ next of kin
are notified promptly when a prisoner becomes seriously ill and that there is a full
record of contact and action taken.
• The Governor should ensure that if a prisoner is suspected of, or confirmed as
having contracted COVID-19, he is given the opportunity for someone to be notified.
• The Governor should ensure that documents are securely stored and promptly
provided to the Prisons and Probation Ombudsman following a death in custody, in
line with Prison Service Instruction 58/2010.
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The Investigation Process
8. NHS England commissioned an independent clinical reviewer to review Mr Mears’
clinical care at HMP Channings Wood.
9. The PPO investigator investigated the non-clinical issues, including aspects of the
prison’s response to COVID-19 and shielding prisoners; Mr Mears’ location; the
security arrangements for his journey and admission to hospital; liaison with his
family; and whether early release was considered.
10. The clinical reviewer and investigator jointly interviewed three members of
healthcare staff on 16 and 17 November. The interviews were conducted by
telephone, due to the COVID-19 restrictions in place at that time.
11. The Ombudsman’s family liaison officer wrote to Mr Mears’ next of kin, his wife, to
explain the investigation. She did not receive a reply.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
They did not find any factual inaccuracies.
Previous deaths at HMP Channings Wood
13. Mr Mears was the sixth prisoner at Channings Wood to die since August 2019.
Three of the previous deaths were from natural causes (two due to COVID-19), one
was self-inflicted, and one was drug-related. There has since been a further death
from natural causes, unrelated to COVID-19. We have previously made a
recommendation about the inappropriate use of restraints.
COVID-19 (coronavirus)
14. COVID-19 is an infectious disease that affects the lungs and airways. It is mainly
spread through droplets when an infected person coughs, sneezes, speaks or
breathes heavily. On 11 March 2020, the World Health Organisation (WHO)
declared COVID-19 a worldwide pandemic.
15. COVID-19 can make anyone seriously ill, but some people are at higher risk of
severe illness and developing complications from the infection. People at high risk
(clinically extremely vulnerable) include those who have had an organ transplant;
have severe lung or kidney disease; or are having certain types of cancer or other
treatment which significantly increases the risk of infection. Examples of those at
moderate risk (clinically vulnerable) are people over 70; people under 70 with an
underlying health condition, such as diabetes, or chronic respiratory, heart, liver or
kidney disease; those with a weakened immune system; or who are very
overweight. (These lists are not exhaustive.)
16. In response to the initial pandemic outbreak, HM Prison and Probation Service
(HMPPS) introduced several measures to try and contain the outbreak - to be
implemented at local level, depending on the needs of individual prisons. (An
outbreak is defined as two or more prisoners, or staff, who are clinically suspected,
or have tested positive for COVID-19 within 14 days.) A key strategy is
‘compartmentalisation’ to cohort and protect prisoners at high and moderate risk;
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isolate those who are symptomatic; and separate newly-arrived prisoners from the
main population. Other measures include social distancing and the use of personal
protective equipment (PPE).
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Key Events
17. Mr David Mears was remanded to prison on 22 April 2016, charged with a sexual
offence. He was later convicted and sentenced to life imprisonment, with a
minimum period to serve of 8 years. On 11 April 2019, Mr Mears transferred to
HMP Channings Wood.
18. At an initial health screen, Mr Mears’ health conditions were recorded as type 2
diabetes, heart disease, asthma, anxiety and depression. No secondary health
screen took place, and no care plans were created. On 19 April, a prison GP
referred him to the mental health team.
19. Due to reduced mobility, Mr Mears used a walking frame and a wheelchair for
longer distances. A prison buddy helped him with cleaning and collecting meals.
20. Mr Mears’ diabetes was poorly controlled. He did not always take his insulin and
other medication, so he was not permitted to keep it in his cell. He was expected to
collect it daily, but repeatedly failed to do so as queueing with the other prisoners
made him anxious. Staff then arranged for him to go to the medication hatch after
the other men had left.
21. On 2 May, a detailed mental health assessment concluded that Mr Mears had
anxiety and was coping poorly with his sentence. Although not actively suicidal, he
hoped that by missing his diabetes medication he would die. Due to his thoughts
and passive self-harm, Mr Mears was often managed under the prison’s suicide and
self-harm prevention measures, known as Assessment, Care in Custody and
Teamwork (ACCT).
22. As a result of Mr Mears’ complex mental health problems, he was managed under
the multidisciplinary Care Programme Approach. Concerns were raised several
times about his mental capacity to make decisions about his health and clinicians’
views about this varied over time.
2020
23. At Mr Mears’ annual diabetes foot check on 16 March 2020, the podiatrist found
signs of poor circulation and a loss of sensation. He concluded that Mr Mears was
at moderate risk of diabetic neuropathy (nerve damage).
24. On 6 April, shortly after confirmation of the COVID-19 pandemic, Mr Mears was
handed a letter informing him that he was at high risk of complications if he
contracted the virus and advising him to shield. On 8 April, healthcare staff had a
discussion with him about his risks, but he decided not to shield.
25. The next day, a prison key worker spoke to Mr Mears and other prisoners about the
regime restrictions during the pandemic and requirements such as social distancing
to limit contact with others. During outbreak periods when the prison was in
lockdown, Mr Mears’ prison buddy accompanied him to healthcare every morning to
collect his medication.
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26. Throughout the pandemic, healthcare and safer custody staff reminded Mr Mears of
the option to shield, as well as the risks and possible consequences if he failed to
follow medical advice. He persistently declined and signed disclaimers.
27. On 29 April, Mr Mears received a letter and application form to be considered for
release on temporary licence (ROTL). On 14 May, he was informed that due to a
change in policy, he was no longer eligible, but he could apply for compassionate
release under a special purpose licence. On 11 June, Mr Mears was informed that
his application could not be progressed due to his risk of harm.
28. Over the following months, primary care and mental health staff continued to
monitor and review Mr Mears to help improve his physical and mental health, as
well as his compliance with taking his medication. However, he missed several
medical appointments.
2021
29. Despite initial reluctance, Mr Mears received his first and second COVID-19
vaccines on 30 March and 20 June 2021, respectively.
30. Mr Mears was admitted to hospital on 16 July, due to high blood pressure. He
discharged himself the next day. No abnormalities were found, and healthcare staff
checked him on his return.
31. On 30 July, Mr Mears said he had felt unwell for three days. On examination, a
nurse found that he had a temperature, and his left leg was red/purple, painful and
hot. She removed a drawing pin stuck in the sole of his left foot, just below his
second toe. Mr Mears had been unaware of it, due to the loss of sensation in his
feet. (Prisoners do not have drawing pins in their cells, but they are used on
noticeboards in communal areas.) He received antibiotics and was checked
several times a day, but the infection did not improve.
32. After examining Mr Mears on 4 August, the prison GP suspected sepsis and
osteomyelitis and advised that he needed to be admitted to hospital. Mr Mears was
reluctant to go, although the GP told him he could lose his toe, or foot and it was
potentially life threatening. He was eventually persuaded by wing staff who knew
him well. Mr Mears was escorted by two prison officers and handcuffed with an
escort chain (which was removed on 8 August).
33. Healthcare staff obtained frequent updates on Mr Mears’ condition and reported
significant changes and deterioration to operational managers. On 5 August, it was
noted that he was receiving intravenous treatment for a diabetic foot infection. He
then had two operations to remove toes and was due to have a third on 13 August.
34. On 9 August, Mr Mears asked for his wife to be told that he was in hospital.
35. Mr Mears tested positive for COVID-19 on 10 August. His condition deteriorated
and he became too unstable for surgery.
36. On 13 August, an entry in the escort log noted that the family liaison officer had
spoken to Mr Mears’ wife and passed on the telephone number of the ward.
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37. On 16 August, the hospital said that the priority was treating Mr Mears’ COVID-19
infection, which was more serious than his foot infection and the prognosis was
poor.
38. At around 1.00pm on 17 August, hospital staff asked for the details of Mr Mears’
next of kin and the escort staff passed this request to the prison. A further request
was noted at 3.58pm, as he was not expected to last the night. At 4.01pm, the
escort nurses informed the escort staff that Mr Mears had died.
39. The prison assigned another family liaison officer, who promptly notified Mr Mears’
wife of his death and kept in close contact to explain the procedures and help with
the arrangements.
40. Notices were issued to staff and prisoners, informing them of Mr Mears’ death and
reminding them of the support available.
41. In line with national policy, the prison contributed to the costs of Mr Mears’ funeral,
which was held on 9 September.
Cause of death
42. No post-mortem examination was held, as HM Coroner accepted the cause of
death certified by the hospital as COVID-19 and diabetic foot. Mr Mears also had
underlying type 2 diabetes, asthma and ischaemic heart disease, which had
contributed to, but did not cause, his death.
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Findings
Clinical Findings
43. The clinical reviewer found that healthcare staff at Channings Wood were
compassionate, diligent and attentive in their management of Mr Mears. However,
he also identified several shortcomings and concluded that his clinical care at the
prison was not equivalent to that he could have expected to receive in the
community. Full details of his findings are in the clinical review report. We
summarise below the issues linked to the conditions which caused or contributed to
Mr Mears’ death.
Management of Mr Mears’ risk of infection from COVID-19
44. In line with national HMPPS policy, Channings Wood implemented protective
measures to manage the risks associated with COVID-19, such as a restricted
regime, social distancing and shielding prisoners at high risk of complications from
the virus. Prisoners could continue shielding when it was no longer a mandatory
requirement for the prison to facilitate this.
45. Mr Mears persistently declined to accept medical advice to shield. He tested
positive for COVID-19 six days after admission to hospital. The incubation period of
the virus is thought to be between two and fourteen days, so we cannot say for
certain whether he contracted the infection at Channings Wood, or in hospital.
Monitoring Mr Mears’ long-term medical conditions
46. Mr Mears’ health conditions were identified when he arrived at Channings Wood in
2019. However, the diabetes and hypertension care plans that had been created at
his previous prison were not continued and there were no care plans to manage his
cardiovascular and respiratory disease. There were care plans for medical
compliance and blood sugar monitoring, but the latter was not used.
47. The clinical reviewer found that despite Mr Mears’ challenging stance, healthcare
staff worked hard to encourage him to cooperate with medical advice and take his
medication. They checked his feet and frequently monitored his blood sugar levels.
However, when the levels were high, they were rarely followed up with a urine
analysis, or escalation to senior clinicians for advice on whether he needed targeted
treatment, or admission to hospital.
48. We agree with the clinical reviewer that formal care plans should have been in
place for Mr Mears’ diabetes and other long-term conditions and would have helped
to ensure better clinical management. We recommend:
The Head of Healthcare should ensure that:
• formal care plans are in place to manage patients with chronic health
conditions; and
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• healthcare staff record the details and outcome of assessments in
patients’ medical records; and follow the protocols for escalating
concerns or deterioration.
Mental capacity
49. Due to Mr Mears’ attitude about managing his health and taking his medication,
healthcare staff often questioned his mental capacity. Assessments were carried
out by the prison GP, nurses, the mental health team and a psychologist. Opinions
about his mental capacity varied.
50. The clinical reviewer had several concerns about the handling of mental capacity
assessments. There were delays in acting on concerns that Mr Mears’ blood sugar
levels might have affected his capacity, as well as conflicting opinions on who
should complete the assessments; and, although judgements were made, no formal
assessments were recorded in his medical record. We recommend:
The head of Healthcare should ensure that a formal mental capacity
assessment is promptly completed and fully documented when there are
concerns that a prisoner has declined medical advice or treatment.
Secondary health assessment
51. National Institute for Health and Care Excellence (NICE) Guideline 57, Physical
Health of People in Prison, states that every prisoner should have a second-stage
health assessment within seven days of the initial health screen. There was no
evidence of a secondary assessment.
52. The clinical reviewer considered that the circumstances did not merit a
recommendation. As this omission did not adversely affect Mr Mears’ clinical care
and given the lapse of time since his reception, we make no further comment.
However, the Head of Healthcare will need to be mindful of this issue.
Security risk assessments and the use of restraints
53. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility.
54. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when he has a serious medical
condition. The judgment indicated that medical opinion about the prisoner’s ability
to escape must be considered as part of the assessment process and kept under
review as circumstances change. This is reinforced in Prison Service Instruction
(PSI) 33/2015 External Escorts, which states that handcuffs will not normally be
necessary if a prisoner’s mobility is severely limited, e.g. due to advanced age or
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disability, unless the prison has grounds to believe that an escape might be made
with external assistance.
55. Mr Mears was a category C prisoner, on the enhanced level of the prison’s
incentives scheme, who was assessed as a low risk of escape (on a scale of low,
normal or high). Reduced mobility and wheelchair use were reflected in the
healthcare section of the risk assessment. In spite of this, the authorising prison
manager annotated the form, “appropriate – wheelchair” in reference to use of an
escort chain. The escort chain was removed on 8 August, with a note that the
decision should be reviewed in 24 hours. It does not appear to have been used
again, but we were unable to verify this as Channings Wood could not provide the
relevant escort logs.
56. We consider that the use of restraints was inappropriate, given Mr Mears’ reduced
mobility, intravenous treatment, serious foot infection and surgery. We recommend:
The Governor should ensure that all staff undertaking and reviewing risk
assessments for prisoners admitted to hospital understand the legal position
on the use of restraints, that assessments fully take into account the
prisoner’s health and mobility and are based on the actual risk he presents at
the time.
Notifying Mr Mears’ family of his illness
57. HMPPS guidance on contacting a prisoner’s next of kin during the pandemic states
that if a prisoner is symptomatic, or has contracted COVID-19, they should be given
the opportunity for someone to be informed and, with consent, the prison should
arrange to do this. Additionally, prisons are expected to comply with the existing
policy (set out in Prison Rule 22 and PSI 64/2011) that a prisoner’s next of kin
should be informed immediately if they become seriously ill, or if there is
unpredicted or rapid deterioration in their physical health.
58. There was a delay in contacting Mr Mears’ wife. A brief handover entry (in the
chronology section of the original risk assessment) referred to Mr Mears asking for
his wife to be notified and the escort log suggested that this was done on 13
August. No other contact or actions taken were recorded in the available escort
logs and the family liaison log submitted to the investigation began on the day Mr
Mears died. We recommend:
The Governor should ensure that, in line with national policy, prisoner’s next
of kin are notified promptly when a prisoner becomes seriously ill and that
there is a full record of contact and action taken.
The Governor should ensure that if a prisoner is suspected of, or confirmed
as having contracted COVID-19, he is given the opportunity for someone to
be notified.
59. The omissions identified are no reflection on the family liaison officer appointed on
the day of Mr Mears’ death, who contacted Mr Mears’ wife quickly, provided very
good support in the following weeks and maintained a comprehensive record of
events.
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Provision of documents
60. Despite several requests, the prison was unable to provide the escort logs covering
the period from 4 to 11 August. We recommend:
The Governor should ensure that documents are securely stored and
promptly provided to the Prisons and Probation Ombudsman following a
death in custody, in line with Prison Service Instruction 58/2010.
Sue McAllister CB
Prisons and Probation Ombudsman October 2024
Inquest
The inquest, held on 5 June 2025, concluded that Mr Mears died from natural causes.
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