David Butler

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr David Butler,
a prisoner at HMP Holme House,
on 25 March 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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OFFICIAL - FOR PUBLIC RELEASE
© 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 failure.
3. In July 2018, Mr David Butler was sentenced to six years and six months
imprisonment for drug offences. He died of pancreatic cancer on 25 March 2024, at
HMP Holme House. He was 53 years old. We offer our condolences to Mr Butler’s
family and friends.
4. The Ombudsman’s office contacted Mr Butler’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond
to our letter.
5. NHS England commissioned an independent clinical reviewer to review Mr Butler’s
clinical care at Holme House.
6. The clinical reviewer concluded that the clinical care Mr Butler received was
equivalent to that which he could have expected to receive in the community. She
made no recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Butler’s
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
10. At the inquest held on 13 August 2024 the coroner concluded that Mr Butler died of
natural causes.
Adrian Usher August 2024
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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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
OFFICIAL - FOR PUBLIC RELEASE