David Crowther

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Independent investigation into
the death of Mr David Crowther,
a prisoner at HMP Leeds,
on 11 March 2025
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, 2025
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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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. On 14 January 2025, Mr David Crowther was remanded to HMP Leeds for indecent
assault. He died from sepsis of an unknown cause on 31 January 2025, while a
prisoner at Leeds. He was 83 years old. We offer our condolences to Mr Crowther’s
family and friends.
4. NHS England commissioned, an independent clinical reviewer, to review Mr
Crowther’s clinical care at Leeds.
5. The clinical reviewer concluded that the clinical care Mr Crowther received at Leeds
was of a good standard and was at least equivalent to that which he could have
expected to receive in the community. She found that the emergency response to
Mr Crowther’s deteriorating health was timely. The clinical reviewer made two
recommendations which were not related to Mr Crowther’s death but which the
Head of Healthcare will want to address.
6. The PPO investigator investigated the non-clinical issues relating to Mr Crowther’s
care.
7. We did not identify any non-clinical issues of concern and we make no
recommendations.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
9. At an inquest held on 20 February 2025, the Coroner concluded that Mr Crowther
died of natural causes.
Adrian Usher July 2025
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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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