David Maggs

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Independent investigation into
the death of Mr David Maggs,
a prisoner at HMP Parc,
on 7 May 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
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. In March 2022, Mr David Maggs was sentenced to life imprisonment for murder,
with a minimum tariff of 20 years. He died of myocardial infarction (heart attack) and
pulmonary thromboembolism (blocked blood vessel in lungs) on 7 May 2024, at
HMP Parc. Empyema of gallbladder (inflammation of the gallbladder) and acute
cholangitis (infection of the bile ducts) were listed as contributory factors. He was 73
years old. We offer our condolences to Mr Maggs’ family and friends.
4. The Ombudsman’s office wrote to Mr Maggs’ 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. Healthcare Inspectorate Wales commissioned an independent clinical reviewer to
review Mr Maggs’ clinical care at HMP Parc.
6. The clinical reviewer concluded that the clinical care Mr Maggs received at Parc
was equivalent to that which he could have expected to receive in the community.
He found that there were examples of good quality care, including an appropriate
social services referral, adjustments to Mr Maggs’ cell and excellent care from the
physiotherapy service. The clinical reviewer made recommendations that did not
impact on his assessment of equivalence that the Head of Healthcare will wish to
address. He also stressed that these recommendations would not have affected the
outcome for Mr Maggs.
7. The PPO investigator investigated the non-clinical issues relating to Mr Maggs’
care. She found no non-clinical issues of concern directly impacting Mr Maggs’
death and requiring a recommendation.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
9. Mr Maggs’ family received a copy of the draft report. They did not make any
comments.
Governor and Head of Healthcare to note
10. It took staff six minutes to locate the defibrillator when Mr Maggs was unresponsive,
despite it being on the same wing. The Governor and Head of Healthcare will want
to ensure that all staff are aware of the location of emergency equipment.
Adrian Usher
Prisons and Probation Ombudsman January 2025
Prisons and Probation Ombudsman 1
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Inquest
At the inquest held on 1 September 2025, the Coroner concluded that Mr Maggs died of
natural causes.
2 Prisons and Probation Ombudsman
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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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