Donald Willis

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Independent investigation into
the death of Mr Donald Willis,
a prisoner at HMP Isle of Wight,
on 21 September 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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© 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
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he 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.
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.
Mr Donald Willis died from a stroke on 21 September 2023 at HMP Isle of Wight. He was
85 years old. I offer my condolences to Mr Willis’ family and friends.
The clinical reviewer found that the care Mr Willis received at Isle of Wight was equivalent
to that which he could have expected to receive in the community.
I make no recommendations.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman April 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
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Summary
Events
1. On 25 November 2022, Mr Donald Willis was sentenced to 16 years imprisonment
for sexual offences. On 24 January 2023, he was moved to HMP Isle of Wight.
2. Mr Willis had high blood pressure and was prescribed medication to lower it. He
was not always compliant with taking his medication.
3. On 8 September 2023, an officer found Mr Willis lying on his cell floor during the
morning welfare checks. The officer called a code blue (a medical emergency code
used when a prisoner is unconscious or having breathing difficulties that alerts staff
in the control room to call an ambulance) and healthcare staff attended the cell.
4. The healthcare team checked Mr Willis’ clinical observations, which were normal.
Mr Willis told the healthcare team that he had got up to go to the toilet in the night
and slid down between his bed and his table and was unable to get up. He had no
apparent injuries but did have a small pressure area on the left side of his temple.
Mr Willis was not in any pain and told them that he had not hit his head.
5. As Mr Willis’ condition was stable, the healthcare team stood down the ambulance
and told officers that if his condition deteriorated, he should be taken to the prison’s
inpatient unit and the healthcare team should be contacted.
6. At around 8.30am, Mr Willis’ condition deteriorated, and staff called a code blue.
When the healthcare team arrived, they found Mr Willis had a droop to his mouth
and was unable to raise his left hand. Mr Willis was taken to hospital by ambulance
and was treated for a stroke.
7. On 12 September, Mr Willis was discharged back to the inpatient healthcare unit at
Isle of Wight, where he was cared for in an end-of-life suite.
8. Mr Willis’ health continued to deteriorate and on 21 September he died.
Findings
9. The clinical reviewer concluded that the care Mr Willis received was of a reasonable
standard and was equivalent to that which he could have expected to receive in the
community. She found that the care Mr Willis received following his stroke on 8
September 2023 was of a high standard, specifically the communications and joint
working with a hospice who the healthcare team worked with to develop an end-of-
life care plan for Mr Willis. This is reflective of high quality and compassionate care.
10. We make no recommendations.
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The Investigation Process
11. HMPPS notified us of Mr Willis’ death on 21 September 2023.
12. The investigator issued notices to staff and prisoners at HMP Isle of Wight informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
13. The investigator obtained copies of relevant extracts from Mr Willis’ prison and
medical records.
14. The investigator interviewed two members of staff on 22 November and 19
December.
15. NHS England commissioned an independent clinical reviewer to review Mr Willis’
clinical care at Isle of Wight.
16. We informed HM Coroner for Isle of Wight of the investigation. The Coroner gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
17. The Ombudsman’s family liaison officer contacted Mr Willis’ wife to explain the
investigation and to ask if she had any matters she wanted us to consider. Her
daughter responded on her behalf and asked to know more of the timeline of Mr
Willis’ poor heath and whether he had a COVID-19 booster. We have addressed
these questions in our report and the annexed clinical review.
18. We shared our initial report with HMPPS. They found no factual inaccuracies.
19. We sent a copy of our initial report to Mr Willis’ daughter. She pointed out some
factual inaccuracies in the clinical review, which has been amended and is annexed
to this report. She also raised a query which has been answered in a separate
letter.
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Background Information
HMP Isle of Wight
20. HMP Isle of Wight is an amalgamation of two former prisons, Parkhurst and Albany,
and holds around 1,000 men. Practice Plus Group provides healthcare services at
the prison. There is a healthcare inpatient unit at the Albany site, providing 24-hour
care for prisoners.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Isle of Wight was in September 2022.
Inspectors reported that the prison outcomes for safety, respect, and rehabilitation
and release planning had declined. Staff shortages of both prison officers and more
specialist disciplines was undermining much of the prisons work and attempts at
improvement. Over a third of officers were not available for work in the units, which
limited the delivery of the day-to-day regime and led to prisoners spending too long
locked in cells.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to December 2022, the IMB
reported that persistent staffing shortages across the entire prison staff had slowed
the return to a normal regime following COVID-19. This resulted in prisoners
continuing to be locked up for considerable periods of time and detrimentally
affected prisoners’ access to healthcare appointments.
Previous deaths at HMP Isle of Wight
23. Mr Willis was the thirty-fourth prisoner to die at Isle of Wight since September 2020.
Of the previous deaths, 27 were from natural causes, four were self-inflicted and
two were from unknown causes.
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Key Events
24. On 25 November 2022, Mr Donald Willis was sentenced to 16 years imprisonment
for sexual offences. On 24 January 2023, he was moved to HMP Isle of Wight.
25. Mr Willis had hypertension (high blood pressure). He had been prescribed
medication (indapamide) for this at his previous prison, but he had decided to stop
taking it as he said it interacted with his other medication.
26. On 8 February, a nurse saw Mr Willis and noted that his blood pressure was high.
She started him on weekly blood pressure monitoring and spoke to him about
healthy lifestyle choices and the risk of stroke. She created a hypertension care
plan.
27. On 15 February, healthcare staff carried out a cardiovascular risk score assessment
(QRISK2) for Mr Willis, which showed that he was at a high risk of having a stroke
or a heart attack in the next ten years.
28. Mr Willis had several further high blood pressure recordings. On 24 February, a GP
prescribed indapamide.
29. On 6 April, Mr Willis told healthcare staff that he had not taken his indapamide for
one week. The healthcare team checked his blood pressure which was high.
30. On 24 April, a GP reviewed Mr Willis’ blood pressure reading. The GP suggested
that Mr Willis should take an additional medication to help lower his blood pressure.
Mr Willis did not want to take any more medication. He said that he had white coat
syndrome (when blood pressure is raised due to the stress of a clinical
environment) and had missed his medication for ten days which is why his blood
pressure was high. Mr Willis asked to resume taking indapamide and the GP
agreed.
31. On 20 July, Mr Willis saw the health care team in a clinic. The healthcare team
suggested further medication for high blood pressure and a daytime ambulatory
blood pressure monitor (enables blood pressure to be recorded during normal daily
routine activities and sleep). Mr Willis declined both. Staff assessed that Mr Willis
had capacity to make his own decisions.
32. On 27 July, Mr Willis saw a GP to discuss his high blood pressure. He told the GP
that he had severe white coat syndrome and his blood pressure was normally okay.
He did not want any further blood pressure medication.
8 September
33. An officer found Mr Willis lying on his cell floor during the morning welfare checks.
The officer called a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties that alerts staff in the control room to
call an ambulance) and healthcare staff attended the cell. The Head of Safety
completed an escort risk assessment (ERA) for Mr Willis to be taken out on an
emergency ambulance escort. He assessed that restraints should be applied (a
single set of handcuffs).
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34. The healthcare team checked Mr Willis’ clinical observations, which were normal.
Mr Willis told the healthcare team that he had got up to go to the toilet in the night
and slid down between his bed and his table and was unable to get up. He had no
apparent injuries but did have a small pressure area on the left side of his temple.
Mr Willis was not in any pain and told them that he had not hit his head.
35. The healthcare team stood down the ambulance and offered for Mr Willis to go to
the prison’s inpatient healthcare unit (IHU) for monitoring. Mr Willis declined this.
The healthcare team agreed with Mr Willis and officers that if his condition
deteriorated, he should be taken to the IHU and the healthcare team should be
contacted.
36. At around 8.30am, Mr Willis’ condition deteriorated, and staff called a code blue.
When the healthcare team arrived, they found Mr Willis had a droop to his mouth
and was unable to raise his left hand.
37. As a second code blue had been called, the Head of Safety went to Mr Willis’
houseblock and spoke to two members of the healthcare team. The healthcare
team said that both code blues had been for Mr Willis, his condition had
deteriorated, and an ambulance was on the way. The Head of Safety then
completed an updated ERA which advised that restraints should not be applied to
Mr Willis due to his condition and age.
38. Despite the updated ERA, officers handcuffed Mr Willis for his transfer to hospital.
When he arrived at hospital, staff placed Mr Willis on an escort chain (a long chain
with a handcuff at each end, one of which is attached to the prisoner’s wrist and the
other to an officer’s wrist), which was not removed until 6.00pm that evening, when
escort officers received approval from the duty governor to remove restraints. Mr
Willis was admitted to hospital and was treated for a stroke.
39. While in hospital, Mr Willis had a CT scan which showed he had a blockage in his
carotid artery which had caused a stroke. His condition was stable however his
ability to communicate and mobilise had severely declined.
40. On 11 September, doctors put a Do Not Attempt Resuscitation order in place for Mr
Willis. They agreed that he was no longer for active treatment and started him on
palliative care.
41. On 12 September, Mr Willis was discharged back to the inpatient healthcare unit at
Isle of Wight, where he was cared for in an end-of-life suite.
42. Mr Willis’ health continued to deteriorate and on 21 September he died.
Contact with Mr Willis’ family
43. On 11 September, the prison appointed a family liaison officer (FLO) for Mr Willis,
given his deteriorating condition. Mr Willis had a next of kin on file, however it was
recorded that they were no longer in contact.
44. On 15 September, the FLO contacted Mr Willis’ next of kin, his wife, and informed
her of his poor health.
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45. On 21 September, the deputy family liaison officer contacted Mr Willis’ wife to
inform her that he had died. The prison contributed towards the cost of Mr Willis’
funeral and arranged for his belongings to be returned to his family.
Support for prisoners and staff
46. After Mr Willis’ death, a prison manager debriefed the staff involved in his care to
ensure they had the opportunity to discuss any issues arising, and to offer support.
The staff care team also offered support.
47. The prison posted notices informing other prisoners of Mr Willis’ death and offering
support.
Post-mortem report
48. The post-mortem concluded that Mr Willis died of an ischemic stroke (when the
blood supply to part of the brain is blocked). Ischemic heart disease (heart problems
caused by narrowed heart arteries), chronic kidney disease (where the kidneys do
not work as well as they should) and pulmonary thromboembolism (a blood clot in
the lungs) were also listed as contributing factors.
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Findings
Clinical care
49. The clinical reviewer concluded that the care Mr Willis received at Isle of Wight was
of a reasonable standard that was equivalent to the care he could have expected to
receive in the community.
50. She found that the care Mr Willis received after his stroke on 8 September was of a
high standard. In particular, there was good communication between prison
healthcare staff and a local hospice to develop an end of life care plan for Mr Willis.
She noted that the care given to Mr Willis in the last days of his life appeared to be
compassionate and caring.
51. The clinical reviewer made some recommendations unconnected to Mr Willis’ death
which the Head of Healthcare will wish to address.
Restraints, security and escorts
52. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when suffering from a serious
medical condition. It said that medical opinion about the prisoner’s ability to escape
must be considered as part of the assessment process and kept under review as
circumstances change.
53. When the first code blue was called for Mr Willis, the Head of Safety assessed that
restraints (a single set of handcuffs) should be applied for his transfer to hospital.
However, after the second code blue was called and he realised that Mr Willis’
condition had deteriorated, the Head of Safety updated the ERA to show that
restraints should not be applied. This demonstrated that he had considered Mr
Willis’ health and mobility and he made the appropriate decision that Mr Willis
should not be restrained when taken to hospital. This was good practice.
54. However, in spite of the updated ERA, Mr Willis was taken to hospital in restraints.
This should not have happened. We bring this issue to the Governor’s attention.
Inquest
55. At the inquest, held on 2 December 2025, the Coroner concluded that Mr Willis 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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