David Marsh

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Independent investigation into
the death of Mr David Marsh,
A report by the Prisons and Probation Ombudsman
a prisoner at HMP Lincoln,
on 19 October 2025
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
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 September 2025, Mr David Marsh was sentenced to 14 years imprisonment for
sexual offences. He died in hospital of a heart attack on 19 October, while a
prisoner at HMP Lincoln. He was 70 years old. We offer our condolences to Mr
Marsh’s family and friends.
4. The Ombudsman’s office wrote to Mr Marsh’s son to explain the investigation and
to ask if he had any matters he wanted us to consider. He did not respond to our
letter.
5. NHS England commissioned an independent clinical reviewer to review Mr Marsh’s
clinical care at HMP Lincoln.
6. The PPO investigator investigated the non-clinical issues relating to Mr Marsh’s
care.
7. We did not find any non-clinical issues of concern.
8. The clinical reviewer concluded that the clinical care Mr Marsh received at Lincoln
was equivalent to that which he could have expected to receive in the community.
However, she identified two areas of concern.
9. Mr Marsh had an electrocardiogram (ECG, a test to check the heart’s rhythm) on 25
September, but there was no evidence that the results were reviewed by a GP. The
clinical reviewer considered this particularly concerning as Mr Marsh’s post-mortem
examination found he had scarring of the heart, indicating he had had previous
heart attacks. She also found that Mr Marsh did not have any care plans in place for
his long-term conditions, including heart disease and diabetes. We recommend:
The Head of Healthcare should ensure there is a robust process in place for
ECG results to be reviewed by a GP or appropriately qualified registered
healthcare professional.
The Head of Healthcare should ensure robust processes are in place for the
timely creation of care plans for prisoners with diagnosed long term
conditions.
10. We shared our initial report with HMPPS and the prison’s healthcare provider,
Nottinghamshire Healthcare NHS Foundation Trust. They found no factual
inaccuracies. Nottinghamshire Healthcare NHS Foundation Trust provided an
action plan which has been annexed to this report.
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Adrian Usher March 2026
Prisons and Probation Ombudsman
Inquest
At the inquest, held on 20 April 2026, the Coroner concluded that Mr Marsh died from
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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