David Bentley

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr David Bentley,
a prisoner at HMP High Down,
on 10 March 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
© Crown copyright, 2024
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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 process failure.
3. Mr Bentley died of lung cancer at St Helier hospital on 10 March 2023, while a
prisoner at HMP High Down. He was 63 years old. We offer our condolences to Mr
Bentley’s family and friends.
4. The PPO investigator investigated the non-clinical issues relating to Mr Bentley’s
care. We did not find any non-clinical issues of concern.
5. NHS England commissioned an independent clinical reviewer to review Mr
Bentley’s clinical care at High Down.
6. The PPO family liaison officer wrote to Mr Bentley’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
Bentley’s family asked about the clinical care he received after a hospital scan
discovered a lump on his neck in 2019, while at HMP The Mount. This has been
addressed by the clinical reviewer in her report, which sets out the care Mr Bentley
received in 2019 leading to an MRI appointment where results were recorded as
normal. Mr Bentley’s family asked for a copy of our report.
7. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found one factual inaccuracy, and this report has been amended
accordingly.
8. The clinical reviewer concluded that the clinical care Mr Bentley received was of the
standard reasonably expected and equivalent to that which he could have expected
to receive in the community.
9. The clinical reviewer made one recommendation not related to Mr Bentley’s death,
that the Head of Healthcare will wish to address. She also made one
recommendation related to Mr Bentley’s death:
Recommendation
• The Head of Healthcare should ensure that all patients who have a terminal
diagnosis (irrespective of prognosis) have an advanced care plan in place in
accordance with the NICE guideline [NG142] for ‘end of life care for adults:
service delivery’ (2019).
Inquest
10. The inquest into Mr Bentley’s death concluded on the 24 April 2024. The coroner
confirmed that Mr Bentley died of natural causes.
Prisons and Probation Ombudsman 1
Adrian Usher July 2024
Prisons and Probation Ombudsman
2 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