David Evans

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Independent investigation into
the death of Mr David Evans,
a prisoner at HMP Fosse Way,
on 26 July 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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© Crown copyright, 2025
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Summary
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 David Evans died of metastatic adenocarcinoma of lung (lung cancer that has
spread to other organs) on 26 July 2024, while a prisoner at HMP Fosse Way. He
was 73 years old. We offer our condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Evans received at Fosse
Way was equivalent to that which he could have expected to receive in the
community. However, the clinical reviewer found that advanced care planning
should have been implemented at an earlier stage.
5. We found that Mr Evans was inappropriately restrained when he was admitted to
the hospital in July 2024. His failing health and poor mobility were not properly
considered.
Recommendations
• The Head of Healthcare should ensure that Advanced Care Planning is completed
at an early stage for those patients diagnosed with terminal and incurable cancer.
• The Director should ensure that all staff undertaking risk assessments for prisoners
taken to hospital understand the legal position on the use of restraints, that
authorising managers show on the risk assessment that they have taken this
information into account when assessing a prisoner’s current level of risk, and that
risk assessments are regularly reviewed when a prisoner remains in hospital as an
inpatient.
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The Investigation Process
6. HMPPS notified us of Mr Evans’ death on 26 July 2024.
7. NHS England commissioned an independent clinical reviewer to review Mr Evans’
clinical care at HMP Fosse Way.
8. The PPO investigator investigated the non-clinical issues relating to Mr Evans’ care.
9. We informed HM Coroner for Leicester City & South Leicestershire of the
investigation. The cause of death was determined at the hospital without need for a
post-mortem examination. We have sent the Coroner a copy of this report.
10. The Ombudsman’s office wrote to Mr Evans’ next of kin to explain the investigation
and to ask if she had any matters she wanted us to consider. She asked one
question, which we have addressed in separate correspondences.
11. The initial report was shared with HMP Prison and Probation Services (HMPPS),
and they identified two factual inaccuracies in the clinical review, which has been
amended.
Previous deaths at HMP Fosse Way
12. Mr Evans was the third prisoner to die at Fosse Way since the prison opened on 29
May 2023. Of the previous deaths, one was from natural causes and one was self-
inflicted. To the end of November 2024, there has been one more self-inflicted
death at Fosse Way, one homicide and one unascertained death. There are no
significant similarities between the findings in our investigation into Mr Evans’ death
and the findings from our investigations into the previous deaths.
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Key Events
13. On 3 February 2023, Mr David Evans was convicted of sexual offences and given a
sentence of three years and six months.
14. On 6 September, Mr Evans was transferred to HMP Fosse Way.
15. At the time of his transfer, Mr Evans had been diagnosed with asthma and COPD (a
lung condition that makes it hard to breathe due to blocked airflow).
16. On 1 April 2024, Mr Evans had an asthma and COPD care plan review. He had no
recent flare ups and there is no record of any courses of oral steroids or hospital
admissions in the two years before this.
17. On 10 June, Mr Evans presented with right sided facial droop and slurred speech.
Nurses assessed him and found that he appeared to have recovered fully. A nurse
booked Mr Evans for an urgent GP appointment the next day and advised officers
on his wing to check him overnight.
18. On 11 June, a paramedic at Fosse Way reviewed Mr Evans. He reported that he
had experienced a further 20-minute episode of slurred speech and right sided
facial droop earlier that morning. There was no evidence of facial droop or slurred
speech at the time of the paramedic’s assessment and Mr Evans’ clinical
observations remained within the normal range. The paramedic found that there
were no other neurological symptoms and added Mr Evans to the GP clinic that
day.
19. Later that morning, a GP assessed Mr Evans and diagnosed a Transient Ischemic
Attack (TIA causes symptoms like a stroke and is often referred to as a mini stroke).
The GP referred Mr Evans to the local hospital TIA clinic and prescribed aspirin in
the interim as advised.
20. On 12 June, Mr Evans attended the TIA clinic at Leicester Royal Infirmary. An MRI
scan of his head was normal, and he was discharged.
21. On 16 June, Mr Evans reported pain in his lungs especially on lying down. A nurse
found no urgent clinical cause but referred him to the GP for review. The GP
reviewed Mr Evans’ records the following day and requested an urgent chest X-ray.
22. On 17 June, Mr Evans reported feeling short of breath and having to use his blue
inhaler (salbutamol) four times a day. The assessment indicated low clinical risk.
23. On 18 June, Mr Evans again reported feeling of short of breath. However, this time
the assessment indicated high clinical risk and urgent medical transport to hospital
was required. He returned to Fosse Way the same day having been diagnosed with
suspected pleural effusion (fluid around the lung). Later that evening, his condition
had improved.
24. On 19 June, healthcare staff assessed Mr Evans’ condition in the morning and
there was no clinical concern. However, by the evening he appeared to have
deteriorated significantly. He was taken to Leicester Royal Infirmary.
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25. On 20 June, Mr Evans discharged himself against medical advice.
26. On 21 June, Mr Evans attended his appointment at Glenfield Hospital for an X-ray
and CT scan. The CT scan confirmed a diagnosis of lung cancer with extensive
metastasis (spread). The scan also confirmed a pleural effusion which was
contributing to his shortness of breath. While in hospital, Mr Evans had a chest
drain inserted (to drain the fluid around his lung) and was treated with oxygen
therapy. Mr Evans remained as an inpatient in Glenfield Hospital until 4 July, when
he was deemed medically fit for discharge. He was discharged back to Fosse Way
with a chest drain in place.
27. On return to Fosse Way, Mr Evans was noted to be frailer than previously and now
used a Zimmer frame to aid his mobility. His prognosis was terminal and there was
no further curative treatment available to him. He was referred to the integrated
community specialist palliative care team.
28. On 5 July, healthcare staff called an ambulance after Mr Evans presented with right
sided weakness and slurred speech. However, when the paramedics arrived he had
no further signs of a stroke and therefore he decided to stay at Fosse Way.
29. On 10 July, Mr Evans’ condition deteriorated and he was transported to hospital.
Restraints (a single handcuff attaching him to an officer) were authorised for use.
Prison staff recorded that Mr Evans was a low risk of escape and medium risk to
the public. A nurse completed the medical assessment of the escort risk
assessment and identified that Mr Evans used a wheelchair. She did not object to
the use of restraints. Mr Evans returned to Fosse Way on 11 July.
30. On 12 July, healthcare staff sent Mr Evans to hospital again following concerns
regarding a deterioration of his condition. This time, the medical assessment did not
identify any mobility issues and again did not object to the use of restraints. As
previously, single handcuffs were authorised. Mr Evans was discharged the
following day with a course of oral antibiotics.
31. On 15 July, Mr Evans was admitted to Leicester Royal Infirmary due to a
deterioration of his condition. He was diagnosed with a chest infection and treated
with intravenous antibiotics, diuretics and was reviewed by the inpatient palliative
care team. During this admission, he gradually deteriorated.
32. A nurse completed the medical assessment of the escort risk assessment and
noted that Mr Evans used a walking frame. They did not object to the use of
restraints. The risk assessment concluded that single handcuffs should be applied.
33. Later on 15 July, the duty operational manager recorded that “due to Mr Evans
requiring a wheelchair and significant lack of mobility, use of escort chain is
authorised”.
34. On 23 July, prison staff were notified that Mr Evans’ prognosis was poor and he was
nearing the end of his life. A security manager authorised the removal of restraints.
35. At 2.12 pm on 26 July, Mr Evans died.
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Post-mortem report
36. The Coroner chose not to request a post-mortem examination and relied on the
cause of death proposed by the hospital. This was recorded as metastatic
adenocarcinoma of the lung (lung cancer which was spread to other organs).
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Findings
Clinical findings
37. The clinical reviewer considered that the care Mr Evans received at Fosse Way was
of a good standard and equivalent to that which he could have expected to receive
in the community. He found that Mr Evans received good care for his terminal
illness while in Fosse Way. The clinical reviewer noted that Mr Evans was
diagnosed at a late stage and hence intervention and treatment were not possible.
He received attentive care from the nursing and GP team in Fosse Way and was
referred to hospital for further care appropriately.
38. The clinical reviewer did note that during the final month of Mr Evans’ life he was
admitted to hospital several times, on two occasions for only one night. This was
clearly distressing for him and some of these admissions may have been avoided
by earlier completion of an Advanced Care Plan and assessment by the community
palliative team in Fosse Way. We make the following recommendation:
The Head of Healthcare should ensure that Advanced Care Planning is
completed at an early stage for those patients diagnosed with terminal and
incurable cancer.
Restraints, security and escorts
39. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when suffering from a serious
medical condition. It said that medical opinion about the prisoner’s ability to escape
must be considered as part of the assessment process and kept under review as
circumstances change.
40. Mr Evans was a 73-year-old man, who had a history of poor health including
shortness of breath and COPD. Following his return from hospital in early July
2024, he was noted to be much frailer than previously and required mobility aids.
He also had a short prognosis of around eight weeks to live.
41. In his hospital admissions later that month, healthcare staff did not identify Mr
Evans’ prognosis and diagnosis in the escort risk assessment, and did not always
identify his mobility issues. Even when Mr Evans’ poor mobility was recognised,
operational staff continued to authorise some form of restraints. The escort chain
was not removed until hospital staff identified that Mr Evans was very close to
death.
42. Mr Evans’ symptoms, mobility, age and prognosis, in line with the High Court
judgement, meant that his risk could have been effectively managed on each of
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these occasions by the officers accompanying him, without the use of restraints.
The decision to restrain him was not proportionate to his risk.
43. We frequently raise concerns about how well healthcare staff understand, or feel
empowered, to make a meaningful contribution to the risk assessment process,
such as in this case. In March 2024, we recommended that NHS England develop
national guidance for establishments to develop local standard operating
procedures for healthcare input into restraints risk assessments. This
recommendation was accepted, and NHS England told us that they are working
with HMPPS to review the Prevention of Escapes – External Escorts Policy
Framework, with particular focus on the escort risk assessment. We also welcome
the work that the Operational Security Group Director has undertaken to review and
amend the national risk assessment form, mandate its use and provide additional
guidance to staff responsible for making decisions about the use of restraints.
44. We have not previously made any recommendations about the use of restraints at
Fosse Way. Nevertheless, it is important that staff properly consider the prisoner’s
age, health and mobility when determining the appropriate use of restraints. While
the work of HMPPS and NHS England is ongoing, we make the following
recommendation:
The Director should ensure that all staff undertaking risk assessments for
prisoners taken to hospital understand the legal position on the use of
restraints, that authorising managers show on the risk assessment that they
have taken this information into account when assessing a prisoner’s current
level of risk, and that risk assessments are regularly reviewed when a
prisoner remains in hospital as an inpatient.
Inquest
45. The inquest into Mr Evans’ death concluded on 25 November 2024 and returned a
verdict of natural causes.
Adrian Usher
Prisons and Probation Ombudsman July 2025
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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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