David Leary

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Independent investigation into
the death of Mr David Leary,
a prisoner at HMP Wymott,
on 5 April 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, 2025
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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 3 July 2009, Mr David Leary was sentenced to five years in prison for sex
offences.
4. He died in hospital from sepsis of an unknown cause on 5 April 2024, while a
prisoner at HMP Wymott. (Sepsis is a life-threatening condition that occurs when
the body’s response to an infection damages vital organs.) Mr Leary was 74 years
old. We offer our condolences to his family and friends.
5. The PPO family liaison officer wrote to Mr Leary’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.
6. NHS England commissioned an independent clinical reviewer, to review Mr Leary’s
clinical care at Wymott.
7. The clinical reviewer concluded that the clinical care Mr Leary received at Wymott
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 healthcare staff made a
number of attempts to get Mr Leary to engage with his clinical care, and they
regularly assessed his mental capacity when he refused to engage. The clinical
reviewer made a recommendation which was not related to Mr Leary’s death but
which the Head of Healthcare will want to address.
8. The PPO investigator investigated the non-clinical issues relating to Mr Leary’s
care. We did not identify any significant non-clinical learning and 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. Mr Leary’s family received a copy of the draft report. They did not make any
comments.
Adrian Usher October 2024
Prisons and Probation Ombudsman
At an inquest held on 5 December 2024, the Coroner concluded that Mr Leary died of
natural causes.
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