Roy Whitehouse

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into the
death of Mr Roy Whitehouse,
a prisoner at HMP Oakwood,
on 21 October 2023
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 August 2021, Mr Roy Whitehouse was sentenced to ten years imprisonment for
sexual offences. He died in hospital of severe thyrotoxicosis on 21 October 2023,
while a prisoner at HMP Oakwood. He was 76 years old. We offer our condolences
to Mr Whitehouse’s family and friends.
4. The PPO family liaison officer wrote to Mr Whitehouse’s son to explain the
investigation and to ask if he had any matters he wanted us to consider. He did not
respond to our letter.
5. The PPO investigator investigated the non-clinical issues relating to Mr
Whitehouse’s care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Mr
Whitehouse’s clinical care at HMP Oakwood.
7. The clinical reviewer concluded that the clinical care Mr Whitehouse received at
Oakwood was partially equivalent to that which he could have expected to receive
in the community. She made two recommendations related to his death.
8. We make the following recommendations related to the clinical care Mr Whitehouse
received:
• The Head of Healthcare and the provider’s Lead GP must be assured that
all staff are fully aware of the local operating procedure related to “GP
referrals to hospital” and that this is followed at all times.
• The Head of Healthcare and the Lead GP should review the terms of
reference of the multi-professional complex case clinic/conference
(MPCCC) process to ensure that:
• crucial information is appropriately reviewed and shared at meetings,
and
• patients receive continuity of care.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
9. We shared our initial report with HMPPS and the healthcare provider at Oakwood.
They found no factual inaccuracies in this report. The healthcare provider pointed
out some minor factual inaccuracies in the clinical review report which has been
amended. The healthcare provider provided an action plan which is annexed to this
report.
Adrian Usher
Prisons and Probation Ombudsman March 2024
Inquest
The inquest, held on 30 October 2024, concluded that Mr Whitehouse died from natural
causes. The medical cause of death recorded was hypoxic brain injury caused by chronic
obstructive pulmonary disease (COPD – lung disease), congestive cardiac failure (heart
failure), chest infection and sleep apnoea (when breathing stops and starts during sleep).
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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