David Mace

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr David Mace,
a prisoner at HMP Dartmoor,
on 11 August 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concern
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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. In March 2015, Mr Mace was sentenced to 204 months in prison for sexual
offences. He died of bronchopneumonia on 11 August 2024, at HMP Dartmoor. He
was 68 years old. We offer our condolences to Mr Mace’s family and friends.
4. The Ombudsman’s office wrote to Mr Mace’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.
5. NHS England commissioned an independent clinical reviewer to review Mr Mace’s
clinical care at Dartmoor.
6. The clinical reviewer concluded that the clinical care Mr Mace received at Dartmoor
was largely of a reasonable standard and equivalent to what he could have
expected to receive in the community. He found that regular, well documented
meetings were held at Dartmoor about Mr Mace’s care. Healthcare staff showed
him respect regarding his preferences for treatment, and those discussions were
managed well. However, the missed opportunity to diagnose diabetes earlier while
in another prison was not equivalent. The clinical reviewer made recommendations
not related to Mr Mace’s death that the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Mace’s
care.
8. 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.
Adrian Usher March 2025
Prisons and Probation Ombudsman
At the inquest held on 3 June 2025, the coroner concluded Mr David Mace died of natural
causes.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
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