David Willis

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Independent investigation into
the death of Mr David Willis,
a prisoner at
HMP Standford Hill,
on 28 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. In 1987, Mr David Willis was sentenced to life imprisonment for a violent offence.
He died of respiratory failure caused by acute respiratory distress syndrome-like
lung changes on 28 June 2024, at HMP Standford Hill. (ARDS happens when the
lungs are not working properly due to fluid build-up and low oxygen levels.) Chronic
obstructive pulmonary disease (COPD- a lung disease), lung cancer and prostate
cancer were listed as contributory factors. Mr Willis was 79 years old. We offer our
condolences to Mr Willis’ friends and family.
4. The Ombudsman’s office wrote to Mr Willis’ next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not
respond.
5. NHS England commissioned an independent clinical reviewer to review Mr Willis’
clinical care at HMP Standford Hill.
6. The clinical reviewer concluded that the clinical care Mr Willis received at Standford
Hill was equivalent to that which he could have expected to receive in the
community. She found that Mr Willis received compassionate, consistent and timely
care, managed effectively with care plans. She also noted that there was good
communication between healthcare and prison staff. She found areas of good
practice as he had access to a named nurse for chronic/life limiting illnesses who
had a constant presence throughout his care at Standford Hill. The clinical reviewer
made two recommendations that did not impact on her assessment of equivalence,
that the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Willis’ care.
We did not identify any significant non-clinical learning related to Mr Willis’ death
and we make no recommendations.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Good Practice
9. The compassion demonstrated by both prison and healthcare staff in looking after
Mr Willis was commendable. He had a named nurse who was involved in holistically
planning his care and he was actively involved in decisions affecting this. The
prison arranged taxis to take him to medical appointments (rather than him using
public transport), he was moved to a single room and provided with a radio so he
could summon help if needed. Officers made considerable efforts during the
Prisons and Probation Ombudsman 1
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emergency response, which also included support from prisoners. Several staff
attended his memorial service indicating how well they had got to know him.
10. At the inquest held on 24 April 2025, the Coroner concluded that Mr Willis died of
natural causes.
Adrian Usher April 2025
Prisons and Probation Ombudsman
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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