Wayne Simmonds

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Independent investigation into the
death of Mr Wayne Simmonds,
a prisoner at HMP Leyhill,
on 22 September 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
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© 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. Mr Wayne Simmonds died on 22 September 2023, in a care home, while a prisoner
at HMP Leyhill. His cause of death was a pulmonary embolism (a blockage in the
pulmonary arteries, the blood vessels that send blood to the lungs) caused by a
deep venous thrombosis (a blood clot in a deep vein), which was caused by cancer
of the oesophagus (the tube that connects the mouth to the stomach) and which
had spread to other parts of his body. Mr Simmonds was 50 years old. We offer our
condolences to his family and friends.
4. The PPO family liaison officer wrote to Mr Simmonds’ sister to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Simmonds’s sister asked some questions about the care he received in the care
home, which is outside the remit of our investigation. She also raised some points
about her communication with Leyhill, which we have addressed in separate
correspondence.
5. NHS England commissioned an independent clinical reviewer to review Mr
Simmonds’ clinical care at Leyhill.
6. The clinical reviewer concluded that the clinical care Mr Simmons received at
Leyhill was of a good standard and was at least equivalent to that which he could
have expected to receive in the community. The clinical reviewer found many
examples of good healthcare practice, including prompt referral under the two-week
rule for suspected cancer, promptly arranging GP appointments when necessary,
and giving Mr Simmonds a named nurse who saw him regularly and demonstrated
a thorough approach to Mr Simmonds’ care.
7. The PPO investigator investigated the non-clinical issues relating to Mr Simmonds’
care.
8. Staff at Leyhill arranged for Mr Simmonds to attend hospital on release on
temporary licence. This meant that he could attend his appointments by himself
without the security requirement of officers in uniform accompanying him. We
consider this to have been good practice. We make no recommendations.
9. We shared the initial report with the Prison Service. There were no factual
inaccuracies.
10. We shared the initial report with Mr Simmonds’ sister. She did not respond.
Adrian Usher April 2024
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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Inquest
The inquest, held on 13 November 2023 concluded that Mr Wayne Simmonds died from
natural causes
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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