David Pates

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr David Pates,
a prisoner at HMP Birmingham,
on 28 March 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, 2024
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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 19 July 2007, Mr David Pates was sentenced to 41 months and 15 days in
prison for sexual offences.
4. Mr Pates died of sepsis caused by cellulitis (a serious bacterial skin infection) on 18
March 2024, while a prisoner at HMP Birmingham. He was 79 years old. We offer
our condolences to those who knew him.
5. NHS England commissioned an independent clinical reviewer, to review Mr Pates’
clinical care at HMP Birmingham. The clinical reviewer’s report is attached as
Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Pates received at
Birmingham was of a good standard and equivalent to what he could have expected
to receive in the community. She made two recommendations not related to Mr
Pates’ death that the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Pates’ care.
We did not find any non-clinical issues of concern. We make no recommendations.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
9. At the inquest held on 13 August 2024, the coroner concluded that Mr David
Charles Pates died of natural causes.
Adrian Usher
Prisons and Probation Ombudsman September 2024
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