David Leach

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr David Leach,
a prisoner at HMP Ashfield,
on 10 October 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, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
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 29 April 2021, Mr David Leach was sentenced to eight years in prison for sexual
offences.
4. He died of metastatic hepatocellular carcinoma (liver cancer which spread to other
parts of the body) on 10 October 2023 while a prisoner at HMP Ashfield. He was 85
years old. We offer our condolences to Mr Leach’s family and friends.
5. The PPO family liaison officer contacted Mr Leach’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
6. NHS England commissioned an independent clinical reviewer to review Mr Leach’s
clinical care at HMP Ashfield.
7. The clinical reviewer concluded that the clinical care Mr Leach received at Ashfield
was of a good standard and equivalent to what he could have expected to receive
in the community. She found that Mr Leach’s care was well documented, and staff
were mindful of his needs leading up to, and during the terminal phase of his illness.
The clinical reviewer made recommendations not related to Mr Leach’s death that
the Head of Healthcare will wish to address.
8. The PPO investigator investigated the non-clinical issues relating to Mr Leach’s
care. 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. Oxleas NHS Foundation Trust pointed out some factual inaccuracies with the
clinical review. The investigator passed these onto the clinical reviewer, who
amended their report.
11. At the inquest held on 29 May 2024, the coroner concluded that Mr Leach died of
natural causes.
Adrian Usher April 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