David Marshall

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Independent investigation into
the death of Mr David Marshall,
a prisoner at HMP Hull,
on 16 September 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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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 HM 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. Mr David Marshall was sentenced to 5 years and 15 days for attempted murder and
false imprisonment. He died from bronchopneumonia on 16 September 2023 while
a prisoner at HMP Hull. He also had advanced lung cancer which had spread to
other parts of his body. This contributed to but did not cause his death. He was 51
years old. We offer our condolences to Mr Marshall’s family and friends.
4. The PPO family liaison officer wrote to Mr Marshall’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
asked about the use of restraints and the application for early compassionate
release. The next of kin also asked for a copy of our report.
5. The PPO investigator investigated the non-clinical issues relating to Mr Marshall’s
care including the use of restraints and consideration of early compassionate
release. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Mr
Marshall’s clinical care at HMP Hull. She concluded that the clinical care Mr
Marshall received at HMP Hull was of a good standard and was equivalent to that
which he could have expected to receive in the community.
7. The clinical reviewer made three recommendations, which were not related to Mr
Marshall’s death but which the Head of Healthcare will want to address.
8. 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 June 2024
Prisons and Probation Ombudsman
10. The inquest into Mr Marshall’s death was held on 15 October 2024 and a verdict of
natural causes was recorded. The coroner concluded that Mr Marshall’s death was
due to bronchopneumonia. He also had advanced metastatic lung cancer.
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