Dennis Coe

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Independent investigation into
the death of Mr Dennis Coe,
a prisoner at HMP Moorland,
on 22 March 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, 2025
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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 October 2023, Mr Dennis Coe was sentenced to seven years in prison for sex
offences. He died of respiratory failure caused by a chest infection, in hospital, on
22 March 2025, while a prisoner at HMP Moorland. A prolonged air leak from his
lung, which developed after recent chest surgery for lung cancer, also contributed to
his death. He was 75 years old. We offer our condolences to Mr Coe’s family and
friends.
4. The Ombudsman’s office wrote to Mr Coe’s next of kin, his niece, and his daughter
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. NHS England commissioned an independent clinical reviewer to review Mr Coe’s
clinical care at HMP Moorland.
6. The clinical reviewer concluded that the clinical care Mr Coe received at Moorland
was of a good standard and equivalent to that which he could have expected to
receive in the community. She found that Mr Coe had a care coordinator who
worked closely with a multidisciplinary team, including social care, healthcare staff,
and physiotherapists. She noted effective joint working by the team, with regular,
timely and responsive reviews and weekly meetings to discuss his care. The clinical
reviewer also noted that healthcare staff regularly monitored and recorded Mr Coe’s
weight and prescribed nutritional support drinks to ensure he received adequate
nutrition. She found evidence in the medical records that healthcare and prison staff
treated Mr Coe respectfully and compassionately throughout his care. The clinical
reviewer made no recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Coe’s care.
We did not find any non-clinical issues of concern. We make no recommendations.
Good Practice
8. The family liaison officers demonstrated efforts that went above and beyond in their
compassion and support offered to Mr Coe’s family, which was commendable.
9. The initial report was shared with HM Prison and Probation Service (HMPPS) and
the prison’s healthcare provider, Practice Plus Group. Practice Plus Group pointed
out a factual inaccuracy within the clinical review report which has been amended
accordingly.
10. Mr Coe’s family received a copy of the draft report. They did not make any
comments.
Prisons and Probation Ombudsman 1
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Inquest
11. The inquest hearing was held on 4 April 2025. The Coroner concluded that Mr Coe
died of natural causes.
Adrian Usher
Prisons and Probation Ombudsman September 2025
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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