David Tilley

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Independent investigation into
the death of Mr David Tilley,
a prisoner at HMP Isle of Wight,
on 26 September 2021
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
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Summary
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. Mr David Tilley died in hospital from COVID-19 on 26 September 2021, while a
prisoner at HMP Isle of Wight. He was 70 years old. I offer my condolences to Mr
Tilley’s family and friends.
4. Mr Tilley caught the infection at Isle of Wight as he had not left the prison for
several months.
5. The clinical reviewer found that Mr Tilley’s care was not equivalent to that which he
could have expected to receive in the community. She made recommendations on
vaccine disclaimers; clinical assessment and escalation following a head injury;
monitoring of long-term conditions; clinical tasks; and record keeping.
6. The investigation also found weaknesses in the management of Mr Tilley’s risk of
infection from COVID-19 and the action taken when he reported possible symptoms
of the virus. However, we make no formal recommendations given the changes in
policy and processes since the COVID-19 pandemic.
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The Investigation Process
7. HMPPS notified us of Mr Tilley’s death on 26 September 2021.
8. NHS England commissioned an independent clinical reviewer to review Mr Tilley’s
clinical care at HMP Isle of Wight.
9. The PPO investigator investigated the non-clinical issues.
10. The Ombudsman’s family liaison officer wrote to Mr Tilley’s next of kin, his wife, to
explain the investigation and ask if there were any issues she wanted us to
consider. She did not respond.
11. The initial report was shared with HMPPS, who reported two inaccuracies. These
have been amended.
Previous deaths at HMP Isle of Wight
12. Mr Tilley was the twenty-sixth prisoner at Isle of Wight to die since September 2018.
Of the previous deaths, nineteen were from natural causes (one due to COVID-19)
and six were self-inflicted. There have been eighteen deaths since, fourteen from
natural causes (of which three were COVID-19 related), two self-inflicted and two
awaiting classification. There are no significant similarities between our findings in
this investigation and those in the previous deaths.
COVID-19 (coronavirus)
13. COVID-19 is an infectious disease that affects the lungs and airways. It is mainly
spread through droplets when an infected person coughs, sneezes, speaks or
breathes heavily. On 11 March 2020, the World Health Organisation (WHO)
declared COVID-19 a worldwide pandemic.
14. COVID-19 can make anyone seriously ill, but some people are at higher risk of
severe illness and developing complications from the infection. In response to the
pandemic, HM Prison and Probation Service (HMPPS) introduced several
measures to try and contain outbreaks - to be implemented at local level, depending
on the needs of individual prisons. (A key strategy was ‘compartmentalisation’ to
cohort and protect prisoners at high and moderate risk; isolate those who are
symptomatic; and separate newly arrived prisoners from the main population.)
15. In September 2021, the shielding programme ended in the community, but HMPPS
continued to routinely offer shielding to clinically high-risk prisoners. This has
recently been replaced by a system of individual risk assessments by clinical staff,
to determine the measures necessary to support such prisoners. The agreed
adjustments are documented in a Personal Management Plan, which is then
facilitated by operational staff.
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Key Events
16. Mr David Tilley was convicted of sexual offences on 26 April 2018 and remanded to
HMP Exeter. The next day, he was sentenced to 14 years imprisonment, as well as
an extended licence period of one year in the community. He transferred to HMP
Isle of Wight on 23 August.
17. Mr Tilley had several chronic health conditions, including a mini stroke a week
before he went into prison, low blood pressure, urinary problems, raised cholesterol,
depression and osteoarthritis, which had led to reduced mobility. In August 2019,
Mr Tilley was diagnosed with mild dementia.
18. On 1 April 2020, shortly after confirmation of the COVID-19 pandemic, Mr Tilley was
assessed as at moderate risk of developing complications if he contracted the virus.
Throughout the pandemic, he had regular welfare checks and meetings with his
prison key worker. He also received a weekly COVID-19 newsletter. Wing staff
noted that Mr Tilley understood the altered regimes and how to minimise his risk.
19. Healthcare staff at the prison monitored Mr Tilley’s medical conditions and social
care was provided three times a week from August 2020.
20. In February 2021, the prison considered an application for early release on
compassionate grounds, but Mr Tilley did not meet the criteria.
21. On 10 and 17 February, healthcare staff offered Mr Tilley a COVID-19 vaccination.
He declined both times and signed a disclaimer to confirm this.
Events from 15 September 2021
22. On 15 September, Mr Tilley told wing officers that he had symptoms of COVID-19.
A nurse assessed him. She noted his symptoms as a headache, feeling hot and
cold, as well as problems with smell and taste (which he said were not new). She
told Mr Tilley that he had not described any COVID-19 symptoms, but healthcare
staff would conduct another welfare check the following day. There is no evidence
that this took place.
23. The nurse arranged a GP appointment to discuss urinary problems that Mr Tilley
had mentioned in passing. A prison GP reviewed him on 16 September and noted
that he appeared to be well. There was no reference to COVID-19.
24. In the early hours of 18 September, Mr Tilley told night staff that he had fallen next
to his bed and hit his head. He was assessed by a healthcare assistant and told her
that he had a headache, dizziness and had been nauseous for a few days. She
found no injuries but asked officers to monitor him. Clinical observations, taken at
that time and later in the morning, were within normal range.
25. On 21 September, there was an outbreak of COVID-19 at Isle of Wight. The prison
conducted mass testing of prisoners, but Mr Tilley was not included.
26. Just before 4.00pm on 23 September, Mr Tilley slipped in the bathroom, which he
attributed to weakness in his legs and an officer helped him into bed. A nurse and a
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healthcare assistant assessed Mr Tilley. He said that he had a headache, neck pain
and had felt ‘rough’ for several days. Although he was alert, it was clear to the
healthcare staff that he was very unwell.
27. The nurse took clinical observations and found that Mr Tilley had a low blood
oxygen level. She calculated a score of 10, using the National Early Warning Score
2 (NEWS2), which indicated the need for emergency assessment by a critical care
team and possible high dependency care. (NEWS2 is a clinical assessment tool to
detect acute illness in patients.) She called a code blue medical emergency, and an
ambulance was requested at 4.01pm.
28. Paramedics arrived at 4.25pm and took Mr Tilley to St Mary’s Hospital. He was
accompanied by two prison officers and no restraints were used for the journey (or
in hospital). On arrival, Mr Tilley tested positive for COVID-19. He was initially
admitted to a general ward but moved to the critical care unit that evening.
29. On 24 September, the prison’s family liaison officer told Mr Tilley’s wife that he was
in hospital and gave details of his diagnosis and condition. They spoke again the
following day.
30. Mr Tilley died at 10.00am on 26 September. The family liaison officer broke the
news to his wife within half an hour and offered support.
31. Notices were issued to staff and prisoners, informing them of Mr Tilley’s death and
reminding them of the support available.
Cause of death
32. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Tilley’s cause of death as
COVID-19.
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Findings
Clinical findings
33. The clinical reviewer considered that Mr Tilley’s clinical care was not of a
reasonable standard; and that it was not equivalent to that which he could have
expected to receive in the community. She identified shortcomings in the clinical
assessment and monitoring of Mr Tilley when he reported COVID-19 symptoms and
after a fall with a possible head injury; advanced care planning; management of
long-term conditions; and record keeping.
34. Full details of these findings are in the clinical review report. We reflect in this report
the issues directly linked to Mr Tilley’s cause of death.
35. Mr Tilley contracted COVID-19 at Isle of Wight, as he had not left the prison for
some time.
Head of Healthcare to note
Management of Mr Tilley’s risk of infection and symptoms of COVID-19
36. Mr Tilley was promptly identified as at moderate risk of complications from COVID-
19. At that time, government policy required people at high risk to shield, but
HMPPS’ national policy also allowed those at moderate risk to shield where
individual prisons could facilitate it. There is no evidence that Mr Tilley’s risk was
communicated to him, or that staff discussed the risks and options with him.
However, entries in his personal records later indicated that he understood the
protective measures.
37. The clinical reviewer noted that the disclaimers signed when Mr Tilley refused
COVID-19 vaccines were incomplete, as staff did not record the reasons for his
refusal and whether they had explained the risks and potential consequences. The
clinical reviewer also considered that Mr Tilley should have been tested for COVID-
19 on 15 September, when he reported symptoms of the virus.
38. We are not satisfied that Mr Tilley’s risk was appropriately managed, or that his
concerns about COVID-19 symptoms were handled correctly. Given the lapse of
time and the consequent changes in COVID-19 policy and practice, we make no
formal recommendations, but the Head of Healthcare should note the weaknesses
highlighted.
Adrian Usher
Prisons and Probation Ombudsman November 2023
Inquest
At the inquest, held on 11 August 2025, the Coroner concluded that Mr Tilley died from
natural causes.
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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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