Donald Eaton

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation
into the death of
Mr Donald Eaton, a prisoner
at HMP Holme House, on
25 December 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 Donald Eaton was sentenced to 12 years in prison for sex
offences. He died from liver cancer on 25 December 2024 at HMP Holme House.
He was 73 years old. We offer our condolences to Mr Eaton’s family and friends.
4. The Ombudsman’s office wrote to Mr Eaton’s next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not respond
to our letter.
5. NHS England commissioned an independent clinical reviewer to review Mr Eaton’s
clinical care at HMP Holme House.
6. The clinical reviewer concluded that the clinical care Mr Eaton received at HMP
Holme House was of a good standard and equivalent to that which he could have
expected to receive in the community. She found that Mr Eaton was supported by a
consistent core team on the inpatient unit, and she identified good practice in the
end-of-life care he received. The clinical reviewer did not make any
recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Eaton’s
care.
8. We did not identify any non-clinical learning. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
10. At an inquest held on 28 August 2025, the Coroner concluded that Mr Eaton died of
natural causes.
Adrian Usher
Prisons and Probation Ombudsman May 2025
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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