David Godsave

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Independent investigation into
the death of Mr David Godsave,
a prisoner at
HMP Channings Wood,
on 31 July 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, 2026
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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 David Godsave died of metastatic lung cancer (cancer which had spread) on 31
July 2023 at HMP Channings Wood. He was 78 years old. We offer our
condolences to Mr Godsave’s family and friends.
4. The PPO family liaison officer wrote to Mr Godsave’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
had no questions but asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer, to review Mr
Godsave’s clinical care at HMP Channings Wood. They concluded that the clinical
care Mr Godsave received at HMP Channings Wood was of a reasonable standard
and at least equivalent to that which he could have expected to receive in the
community. The clinical review is attached as Annex 1.
6. The PPO investigator investigated the non-clinical issues relating to Mr Godsave’s
care. We did not find any non-clinical issues of concern. We make no
recommendations.
7. The clinical reviewer made four recommendations which were not related to Mr
Godsave’s death but which the Head of Healthcare will want to address.
8. We shared our initial report with HMPPS and the prison’s healthcare provider. They
found no factual inaccuracies.
9. We sent a copy of our initial report to Mr Godsave’s next of kin. They pointed out
two factual inaccuracies in the clinical review, which have been corrected.
10. At the inquest, held on 28 May 2025, the Coroner concluded that Mr Godsave died
from natural causes.
Adrian Usher December 2025
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