David Wise

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Independent investigation into
the death of Mr David Wise, a
prisoner at HMP Wandsworth
on 15 December 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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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr David Wise died after he was found unresponsive in his cell at HMP Wandsworth on 15
December 2021. He had only been at Wandsworth for 10 days. The post-mortem
examination was inconclusive, so the cause of Mr Wise’s death is not known. He was 46
years old. I offer my condolences to Mr Wise’s family and friends.
The clinical reviewer found that the clinical care Mr Wise received at Wandsworth was
equivalent to that which he could have expected to receive in the community.
Not knowing the cause of Mr Wise’s death has, I am sure, left his family and friends with
many questions. I hope it is of some reassurance that we found no significant gaps in the
care that he was provided with in prison. However, we were unable to obtain CCTV
evidence from Wandsworth and have experienced the same issues in other investigations
at the prison. We also found that Body Worn Video Cameras were not switched on during
the emergency response. Although these issues did not impact on the outcome for Mr
Wise, they should be addressed to ensure responses can be appropriately evidenced in
future.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman March 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
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Summary
Events
1. On 6 December, Mr David Wise was remanded in custody and taken to HMP
Wandsworth.
2. Mr Wise had a history of drug use and was monitored for withdrawal symptoms
during his early days in custody. He was prescribed an antidepressant and other
medications for his mental health issues.
3. On 8 December, Mr Wise presented with symptoms of Covid-19 and was required
to isolate, pending test results. On 11 December, tests confirmed he did not have
Covid-19. However, a mental health assessment did not take place on 12
December, because a wing officer thought Mr Wise was still required to isolate.
4. On 15 December, at around 4.07pm, an officer unlocked Mr Wise’s cell and found
him unresponsive. The officer radioed a medical emergency code (requesting an
ambulance) and started CPR. Paramedics arrived and continued resuscitation, but
at 5.08pm, declared that Mr Wise had died.
5. The post-mortem results were inconclusive, and the cause of Mr Wise’s death is
unknown.
Findings
6. The clinical reviewer concluded that the care Mr Wise received was equivalent to
that which he could have expected to receive in the community. She identified
issues with clinical processes that do not appear to have impacted on Mr Wise’s
death but should be addressed by the Head of Healthcare to improve future care.
7. In the days before he died, staff raised concerns that the cells on Mr Wise’s landing
were too hot. A prison manager confirmed that high temperatures on the wings
were a known problem at the time that Mr Wise was at Wandsworth. There is no
evidence that the cell temperature was linked to Mr Wise’s death, and we found that
the works department acted quickly to address the issue.
8. The investigator was not provided with CCTV footage of the emergency response
when Mr Wise was found unresponsive in his cell. The provision of CCTV footage
has been an issue in other investigations at Wandsworth.
9. No Body Worn Video Cameras (BWVCs) were switched on during the emergency
response when Mr Wise was found unresponsive.
Recommendations
• The Governor should ensure that, as set out in PSI 58/2010, staff provide all
relevant material to the Ombudsman.
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• The Governor should remind staff to switch on their body-worn cameras during
reportable incidents and remind control room operators to prompt staff to do so,
as set out in PSI 04/2017.
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The Investigation Process
10. The investigator issued notices to staff and prisoners at HMP Wandsworth
informing them of the investigation and asked anyone with relevant information to
contact her. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Wise’s prison and
medical records.
12. We informed HM Coroner for Inner West London of the investigation. The
investigation was suspended on 10 January, pending the post-mortem examination
and a cause of death. It was resumed on 16 August, following receipt of the results.
We have sent the coroner a copy of this report.
13. NHS England commissioned a clinical reviewer to review Mr Wise’s clinical care at
the prison. The investigator and clinical reviewer jointly interviewed three prison
and healthcare staff and the investigator interviewed a prison officer and prison
manager. The prisoner who had previously shared a cell with Mr Wise declined to
be interviewed.
14. The Ombudsman’s family liaison officer contacted Mr Wise’s mother to explain the
investigation and to ask if the family had any matters they wanted the investigation
to consider. Mr Wise’s family reflected that contact with the prison FLO was difficult
and there was a delay in the return of Mr Wise’s belongings.
15. Mr Wise’s family received a copy of the initial report. They did not identify any
factual inaccuracies.
16. The prison also received a copy of the report. They did not identify any factual
inaccuracies.
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Background Information
HMP Wandsworth
17. HMP Wandsworth is a local Category B prison in London, with a Category C unit. It
holds up to 1,452 men in eight residential wings. Oxleas NHS Foundation Trust
provides physical and mental healthcare services at the prison. Mental health
services were provided by South London and Maudsley NHS Foundation Trust at
the time of Mr Wise’s death.
HM Inspectorate of Prisons
18. In 2020, HMIP carried out a Short Scrutiny Visit at Wandsworth to look at how the
prison was responding to the Covid-19 pandemic.
19. HMIP reported that primary mental health applications had increased due to
prisoners’ anxieties about their health and regime restrictions, but these were
managed through in cell assessment forms, in-cell work packs and health
information leaflets.
20. In June 2022, HMIP conducted an independent review of progress at Wandsworth.
Inspectors found the new mental health provider (Oxleas) had made progress in
addressing the widespread deficiencies identified at the previous inspection in
2018, and there was now better identification of the mental health needs of new
arrivals.
21. Inspectors reported that standards and living conditions for prisoners on the wings
remained poor.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 May 2021, the IMB reported
concerns about the availability of illicit substances at Wandsworth, which seemed to
trigger aggressive behaviour. The IMB reported that the effects of the Covid-19
pandemic had impacted on healthcare service delivery.
23. The IMB noted the inhumane living conditions at Wandsworth. They outlined in
their report that conditions will only improve when there are substantial structural
changes to the 170-year-old residential buildings and their occupancy. Problems
with heating were noted to be frequent and disruptive.
Previous deaths at HMP Wandsworth
24. Mr Wise was the 12th prisoner to die at Wandsworth since December 2019. Of the
previous deaths, three were from natural causes and eight were self-inflicted.
There has been one natural cause and one self-inflicted death since, and another
where the cause of death is yet to be established.
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Key Events
Arrival at Wandsworth
25. On 6 December, Mr David Wise appeared in court charged with possession and
production of Class A drugs and having an offensive weapon. He was remanded to
HMP Wandsworth, with his next appearance in court scheduled for 23 December.
Mr Wise had been to prison before.
26. On his Person Escort Record (PER - a document that accompanies all prisoners
when they move between police stations, courts and prisons which sets out the
risks they pose), the police recorded that Mr Wise had threatened to harm himself in
2020 and flagged that there was a risk of suicide and self-harm. The PER also
documented that Mr Wise said he had several physical health conditions, including
testicular cancer, asthma, Crohn’s disease (inflammation of the bowel) and that he
had broken his back a few years previously. Mr Wise told prison staff that he had
psychosis, attention deficit hyperactivity disorder (ADHD) and anxiety. Mr Wise
also disclosed that he was dependant on diazepam and amphetamines.
27. A nurse completed Mr Wise’s initial health screen. She noted his physical and
mental health conditions and that Mr Wise had tested positive for amphetamines.
She referred Mr Wise to the prison GP in reception and made referrals to the
mental health team and substance misuse services for further assessment of his
needs. Like all new receptions at the time, Mr Wise was tested for the Covid-19
virus.
28. A prison GP assessed Mr Wise in the reception area. Mr Wise said he had been
diagnosed with testicular cancer around three years prior, which had resulted in
surgery. He was concerned the cancer had returned. The GP said he would ask
another GP to examine Mr Wise the following day. It was not appropriate to
complete this examination during the reception screen because it was a busy area,
without sufficient privacy. The GP assessed that Mr Wise’s mental health appeared
stable.
29. Mr Wise told the prison GP that he had anxiety, depression, and several other
mental health diagnoses, for which he was prescribed medication. He also talked
about his daily use of unprescribed medications (benzodiazepines and diazepam).
The GP completed an assessment of Mr Wise’s withdrawal from these medications
and found that his symptoms were mild. He noted that Mr Wise’s anxiety levels
might have played a part in the result. He continued prescriptions of Mr Wise’s
medications, including an inhaler for his asthma, antipsychotic medication
(quetiapine) and sleeping tablets for three days (zopiclone). Mr Wise was required
to collect his medications from a hatch on the wings because he was not assessed
as suitable for self-administering. The GP created a five-day care plan for the
integrated drug treatment services (IDTS), to monitor Mr Wise’s withdrawal
symptoms. He also noted Mr Wise was unvaccinated and at high risk of developing
complications if he contracted the Covid-19 virus.
30. Following the completion of a cell sharing risk assessment, Mr Wise was moved to
a shared cell on E Wing, the reverse cohorting unit (RCU – where newly arrived
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prisoners were located for 14 days to prevent the spread of Covid-19). Overnight,
Mr Wise slept and showed no signs of withdrawal.
Early days in custody (7 – 14 December)
31. On 7 December, a nurse met with Mr Wise and completed his secondary health
screen. He described Mr Wise as ‘mentally vague’ and referred him to the mental
health team. Mr Wise’s clinical observations were all within normal range and he
declined a Covid-19 vaccination.
32. Another prison GP met with Mr Wise later the same day. He assessed that Mr
Wise’s mental health appeared stable and calm, but that his medication should be
reviewed urgently by the mental health team because of his ‘mentally vague’
presentation that had been reported. Mr Wise was later discussed at a mental
health team meeting who agreed that he was not considered an urgent case but
would be seen within five working days. There is no record that the GP examined
Mr Wise for testicular cancer, as requested the previous day. A pharmacist
confirmed all of Mr Wise’s medications.
33. A substance misuse service recovery worker completed an initial assessment of Mr
Wise’s substance use needs through the window in Mr Wise’s cell door. Mr Wise
outlined his drug use and the recovery worker provided information on harm
reduction. He said he would complete another review as part of his IDTS care plan.
34. On 8 December, a resettlement officer completed a Basic Custody Screening (a
screening tool which covers needs, e.g., accommodation, finances, health) for Mr
Wise. Mr Wise told her that he was homeless, had no physical or mental health
needs, no thoughts of suicide or self-harm but struggled with alcohol and
substances. She referred Mr Wise for a full assessment of his ongoing needs.
35. At 11.18am, a healthcare assistant (HCA) recorded in Mr Wise’s medical record
that he was feeling unwell and that he was having withdrawal symptoms. She
completed his basic observations and the results were normal. At 2.56pm, wing
staff asked healthcare to assess Mr Wise again following complaints that he was
feeling unwell with a temperature, muscle pain and a sore throat. Mr Wise’s blood
pressure was slightly raised, so he and his cell mate were placed in isolation
pending a Covid-19 test result. Basic observations were repeated two hours later
and were all within normal range. He was given paracetamol and later told
healthcare that he felt okay. Mr Wise slept throughout the night. He was observed
regularly and reported no further issues. The next day, Mr Wise declined to speak
to healthcare staff or have his clinical observations taken, but there were no obvious
signs of concern noted by staff.
36. On 10 December, a substance misuse worker and a pharmacist tried to complete a
routine assessment of Mr Wise, regarding his substance misuse and five-day IDTS
care plan. Because Mr Wise was isolated pending his Covid-19 result, they found it
difficult to speak to him through the cell door. The review was re-arranged to take
place once Mr Wise was no longer in isolation.
37. Later that day, an officer recorded in Mr Wise’s prison record that he felt unwell and
was waiting for the results of a Covid-19 test. She noted that a nurse had
completed a routine assessment of Mr Wise and given him his medication.
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38. On 11 December at 1.19pm, an advanced nurse practitioner recorded that Mr Wise
had tested negative for Covid-19 (this result was from the routine test taken shortly
after he arrived at Wandsworth). However, at 5.00pm, an HCA recorded in Mr
Wise’s medical record and made an entry in the wing observation book that Mr
Wise was positive for Covid-19 and was required to isolate until 21 December. He
informed wing staff and put a notice on Mr Wise’s cell door. The HCA later updated
both the medical record and wing observation book to say Mr Wise was in fact
negative for the virus and removed the notice from Mr Wise’s door (he had
confused the results with another prisoner).
39. The next day at 1.34pm, the advanced nurse practitioner recorded that Mr Wise did
not have the Covid-19 virus (the result of the Covid-19 test taken when he was
symptomatic on 8 December). At 4.00pm, a community psychiatric nurse recorded
that she had visited Mr Wise to complete a mental health assessment. Although Mr
Wise said he felt well and would see her outside his cell, an officer (who we have
not been able to identify) advised that he could not unlock him as they thought,
incorrectly, that he was still required to isolate. She told Mr Wise that she would
complete the assessment at a later date, once he had completed his isolation
period. Later, Mr Wise moved to a single cell on the same wing because he was
not getting on with his cell mate.
40. At 11.49pm, night patrol an operational support grade (OSG) made an entry in the
wing observation book that Mr Wise had been using his emergency cell bell
constantly and asking for his door to be unlocked because he wanted to go home
and should not be in prison.
41. On 14 December, an officer unlocked Mr Wise for association and noticed he was
hot and sweating profusely. He encouraged Mr Wise to use the showers. He said
Mr Wise needed help because he did not know how to change the temperature in
the showers. Mr Wise was later found in another prisoner’s cell; this prisoner said
he was scared and described Mr Wise as acting ‘weird’. The officer said the
temperature on E Wing, particularly on the 4s landing where Mr Wise lived, was
very hot. He had reported the problem to the Works Department. He said he took
Mr Wise to the medications hatch to collect his prescription and asked the
pharmacist if Mr Wise should be seen by healthcare. There is no record of this in
Mr Wise’s prison or medical record.
42. At 11.26am, a nurse noted in Mr Wise’s medical record that he had submitted an
application requesting to see someone from the mental health team urgently,
because he was very unwell. The nurse noted that another nurse had attempted to
assess him the previous day but was unable to do so due to Covid-19 isolation
procedures. He recorded that Mr Wise would stay on the ‘green list’ (for low-risk
cases, who should be seen within five working days) and he would complete a
telephone assessment.
43. At 4.09pm, a prison GP completed a review of Mr Wise’s IDTS plan and noted on
his medical record that a further review would be completed after his assessment
with the mental health team.
44. Later in the afternoon, the Works Department attended E Wing in response to
reports that the temperature was too high (there are four separate entries in the
wing observation book between 12 – 15 December that different prisoners had
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complained about the excessive heat). On the record of the visit, the works officer
noted that all the cells on E Wing were hot and requested that the plant room, which
controlled the heating, turn the temperature down. There is a handwritten comment
that the works officer had spoken to Mr Wise, who had not complained about the
temperature.
15 December
45. On 15 December, an officer said he unlocked Mr Wise for association in the
morning (typically lasting around 40 minutes) and encouraged him to have a
shower, but he declined. Mr Wise did not complain about the heat in his cell, but
the officer said he was very sweaty, so he left his door open for longer to allow the
air to flow through. He said he tried to telephone the Works Department about the
heating numerous times, but his calls went unanswered.
46. At 10.05am, a plumber from the Works Department recorded that the pumps to E
Wing had been turned off to help reduce the temperature.
47. At 11.26am, Mr Wise was discussed at the mental health referral meeting. The
meeting noted that a nurse was unable to see Mr Wise to complete his assessment
as he was thought to have tested positive for Covid-19, but that he should have a
full assessment. This did not take place before he died.
48. At around 12.10pm, the officer gave Mr Wise his lunch and locked his cell door.
49. At around 4.07pm, the officer went to Mr Wise’s cell to unlock him for his evening
meal. He said that when he opened the door there was excessive heat emanating
from Mr Wise’s cell. He saw Mr Wise lying on his bed, unresponsive and white in
colour with his eyes and mouth open. His lips were dry. He also described Mr
Wise’s cell as messy and observed that he had not eaten his lunch. He shouted
that a prisoner was not breathing, and he needed help, but said he panicked and
did not use his radio to call a code blue (a medical emergency code used to indicate
that a prisoner is unconscious or having breathing difficulties).
50. A Custodial Manager (CM) was very close by. She heard the officer’s call for help,
radioed a code blue and responded to the emergency along with other prison
officers and healthcare staff who were on the wing. Mr Wise was moved to the floor
and healthcare staff started cardiopulmonary resuscitation (CPR). They attached a
defibrillator which indicated there was no shockable rhythm. Mr Wise was
described as warm to touch, but his eyes were fixed and dilated, there was
discolouration to his skin and signs of cyanosis (indicating a lack of oxygen).
51. London Ambulance Service received a request for an ambulance at 4.07pm.
Paramedics arrived at 4.15pm and continued resuscitation attempts. However, at
5.08pm they declared that Mr Wise had died.
52. At 4.20pm, a nurse recorded that he had tried to contact Mr Wise via his in-cell
telephone, to follow up his reports that he was feeling unwell. His intention was to
complete a triage (an initial assessment) and a welfare check, but there was no
answer. We have not been able to establish exactly when the nurse rang Mr Wise’s
cell telephone.
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Contact with Mr Wise’s family
53. The prison appointed a family liaison officer (FLO). Under normal circumstances,
national prison policy requires that the next of kin is informed of a death in person
by a FLO, wherever possible. However, at the time of Mr Wise’s death exceptional
measures were in place due to the Covid-19 pandemic. This allowed for telephone
contact with a prisoner’s next of kin. The contact telephone number Mr Wise had
given for his parents was incorrect, and the police were asked to assist. They
informed Mr Wise’s family he had died.
54. The FLO contacted Mr Wise’s parents the next day and offered ongoing support.
After that, she contracted Covid-19, which led to a delay in returning Mr Wise’s
belongings to his family. The prison contributed towards the costs of Mr Wise’s
funeral in line with national policy.
Support for prisoners and staff
55. After Mr Wise’s death, the Duty Governor debriefed all the staff involved in the
emergency response, to ensure they had the opportunity to discuss any issues
arising, and to offer support. An officer also attended to support staff in her capacity
as a care team member. The officer who discovered Mr Wise said that although he
was offered immediate support, he did not feel he was given sufficient support in
the days after Mr Wise died.
56. The prison posted notices informing other prisoners of Mr Wise’s death and offering
support. Staff reviewed all prisoners considered to be at risk of suicide and self-
harm in case they had been adversely affected by Mr Wise’s death.
Post-mortem report
57. The post-mortem examination could not identify the cause of Mr Wise’s death and
gave the result as ‘unascertained’ and toxicology results indicated no signs of illicit
drug use.
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Findings
Cause of death
58. The post-mortem was inconclusive and Mr Wise’s death recorded as
unascertained. There is no indication that he took any illicit substances. We do not
consider that prison staff could have foreseen an imminent risk to life in the days
leading up to Mr Wise’s death and we found no significant gaps in the support that
he was provided.
Clinical Care
59. The clinical reviewer concluded that the clinical care Mr Wise received at
Wandsworth was equivalent to that which he could have expected to receive in the
community. She identified some areas for improvement, which are detailed in the
clinical review report. These issues did not directly impact on the outcome for Mr
Wise, but the Head of healthcare should address the recommendations to improve
future care.
Cell temperature on E Wing
60. E Wing was experiencing heating issues during the time that Mr Wise was there,
with various sources complaining that the cells were too hot. The IMB has
highlighted this issue to prison managers. An officer noted that although Mr Wise
did not raise any concerns, several other prisoners had complained, and this was
logged in the wing observation book. He reported the high temperature to the
Works Department and encouraged Mr Wise to shower and get some fresh air
when he was observed to be sweating excessively. A plumber visited on 15
December, to switch off the heating pump. We are satisfied that the response was
timely.
Providing evidence to the PPO
61. In line with Prison Service Instruction (PSI) 58/2010 - The Prisons & Probation
Ombudsman, the investigator contacted Wandsworth’s prison liaison officer
immediately following Mr Wise’s death, and requested relevant information and
evidence needed to investigate the circumstances of his death. CCTV was not
provided despite numerous requests and this is not the first investigation following
the death of a prisoner at Wandsworth where this has been an issue.
62. We note that in their latest report, the IMB raised concerns about the CCTV system
stating that it was unreliable and not fit for purpose. However, in other PPO
investigations, even after a significant delay in some cases, footage has ultimately
been provided. As outlined in the PSI, it is the prisons responsibility to provide the
evidence requested in a timely manner. We therefore repeat the following
recommendation:
The Governor should ensure that, as set out in PSI 58/2010, Wandsworth
provide all relevant material to the Ombudsman.
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Body Worn Video Cameras
63. PSI 04/2017, Body Worn Video Cameras (BWVC), requires prison staff to use
BWVCs during any reportable incident, including medical emergencies. It requires
staff to start recording at the earliest opportunity, to maximise the material captured
by the camera. BWVC’s are an important source of evidence for PPO
investigations, and wider learning for prisons following an incident.
64. Body worn video cameras were not activated when Mr Wise was discovered
unresponsive. This, coupled with the lack of CCTV footage, meant we had no visual
evidence of the emergency response. Based on the other evidence available to us,
we are satisfied that the response was appropriate. We also recognise that during
an emergency event staff might forget to switch on their cameras. However, the
Governor should address this learning to ensure evidence is available in future
incidents. We make the following recommendation:
The Governor should remind staff to switch on their body-worn cameras
during reportable incidents and remind control room operators to prompt
staff to do so, as set out in PSI 04/2017.
Inquest
65. The inquest into Mr Wise’s death concluded in August 2024. The cause of death
was due to hyperthermia, secondary to ambient temperature, infection and
(therapeutic) amphetamine use. A narrative verdict was reached; issues with the
heating system (probably contributing) to past and present health conditions and
lifestyle (possibly contributing).
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