Donald Moore

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Donald Moore,
a prisoner at HMP Wymott,
on 7 July 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, 2024
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
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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 2006, Mr Donald Moore received an Indeterminate sentence for Public
Protection (IPP) for sexual offences. He received a minimum term of four years,
nine months and 26 days. Mr Moore died of disseminated malignant mesothelioma
on 7 July 2023, at HMP Wymott. He was 82 years old. We offer our condolences to
Mr Moore’s family and friends.
4. The PPO family liaison officer wrote to Mr Moore’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. We did
not receive a response.
5. NHS England commissioned an independent clinical reviewer to review Mr Moore’s
clinical care at HMP Wymott.
6. The clinical reviewer concluded that the clinical care Mr Moore received at HMP
Wymott was variable. Some areas of Mr Moore’s care were equivalent to what he
could have expected to receive in the community. However, she found some areas
of learning for the healthcare team relating to the limited monitoring of Mr Moore’s
condition and adherence to NICE guidance for fall risk assessments. The clinical
reviewer made recommendations not related to Mr Moore’s death that the Head of
Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Moore’s
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 1 May 2024, the coroner concluded that Mr Moore died of the
industrial disease of mesothelioma.
Adrian Usher March 2024
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
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