Edward Owens

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Independent investigation into
the death of Mr Edward Owens,
a prisoner at HMP Dartmoor, on
4 November 2022
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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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 Owens died of bronchopneumonia caused by end stage chronic obstructive
pulmonary disease (COPD) in Kingsbridge Hospital on 4 November 2022, while a
prisoner at HMP Dartmoor. He was 77 years old. We offer our condolences to Mr
Owens’ family and friends.
4. The clinical reviewer concluded that the clinical care Mr Owens received at HMP
Dartmoor was of a reasonable standard and at least equivalent to that which he
could have expected in the community. She highlighted examples of good practice
and opportunities for improvement in areas not directly related to Mr Owens’ death,
for the Head of Healthcare to address.
5. We found no non-clinical issues of concern.
6. This version of my report, published on my website, has been amended to remove
the names of staff and prisoners involved in my investigation.
Prisons and Probation Ombudsman 1
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The Investigation Process
7. We were notified of Mr Owens’ death on 4 November 2022.
8. NHS England commissioned an independent clinical reviewer, to review Mr Owens’
clinical care at HMP Dartmoor.
9. The PPO investigator investigated the non-clinical issues relating to Mr Owens’
care.
10. The PPO family liaison officer wrote to Mr Owens’ next of kin, his cousin, to explain
the investigation and to ask if he had any matters he wanted us to consider. He
asked to receive a copy of this report and did not submit any questions.
11. Mr Owens’ family received a copy of the draft report. They did not make any
comments.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out a typographical error and this report has been amended
accordingly. They did not find any factual inaccuracies.
Previous deaths at HMP Dartmoor
13. Mr Owens was the 14th prisoner to die at HMP Dartmoor since 4 November 2019.
Of the previous deaths, eight were from natural causes and two were self-inflicted.
There are no similarities between our findings in this investigation and our
investigation findings for the previous deaths.
2 Prisons and Probation Ombudsman
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Key Events
2018- 2021
14. On 21 October 2014, Mr Owens was given a 20-year sentence for sexual offences
and transferred to HMP Exeter. On 12 January 2018, Mr Owens transferred to HMP
Dartmoor.
15. Mr Owens had COPD (a group of lung conditions that cause breathing difficulties),
conductive deafness, ischemic heart disease, chronic kidney disease and prostate
cancer. The prison healthcare team created care plans to manage these conditions
and provided regular medications.
16. In January 2015, Mr Owens experienced acute exacerbation of his COPD, which
was treated with medications.
17. In September, blood tests results showed a decline in Mr Owens’ kidney function.
Mr Owens was admitted to hospital and treated for acute kidney failure and
pneumonia. He was treated and then returned to prison on 25 September.
18. In October, November and December 2018, Mr Owens had several blood tests to
review his kidney function and staff referred him for an appointment with a urology
specialist.
19. On 24 January 2021, Mr Owens’s received treatment for a further acute
exacerbation of his COPD.
20. On 4 and 5 February, Mr Owens received treatment in hospital for acute abdominal
pain. He returned to prison on 5 February.
21. On 11 March, Mr Owens received antibiotics and oral steroids for a further acute
exacerbation of COPD.
22. On 22 October, Mr Owens attended a urology review and was prescribed
medication which was not issued until 2 April 2022. The reasons for the delay were
not recorded.
2022
23. Throughout 2022, Mr Owens attended urology reviews every three months to
monitor his kidney function. The hospital provided dietary advice which they noted
HMP Dartmoor sometimes struggled to fulfil.
24. On 16 September, a Senior Primary Care Nurse completed a clinical history review
for Mr Owens and assessed his clinical observations. She noted that his levels of
consciousness and oxygen saturation were reduced so called a code blue (an
emergency code triggering a request for an ambulance). Paramedics arrived soon
after and transferred Mr Owens to hospital. The hospital treated Mr Owens for an
exacerbation of his COPD, acute kidney injury, chronic kidney disease and chronic
respiratory failure. He was given antibiotics and intravenous fluids but his health did
not improve. Hospital staff advised Mr Owens that no further treatment could be
offered due to his poor health.
Prisons and Probation Ombudsman 3
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25. On 20 September, HMP Dartmoor nominated a Prison Family Liaison Officer (FLO).
The FLO contacted Mr Owens’ cousin and next of kin and advised him that Mr
Owens was unwell in hospital and receiving end-of-life stage care.
26. On 21 September, staff started an application for early release on compassionate
grounds for Mr Owens.
27. On 24 September, Mr Owens was referred to a Palliative Care Team.
28. On 28 September, Mr Owens’ two cousins visited him in hospital.
29. On 3 October, medical staff indicated that Mr Owens’ prognosis was three to six
months left to live. They considered that he was medically fit for discharge but staff
at Dartmoor raised concerns that they would be unable to meet his medical needs
in a prison setting. He remained in hospital.
30. On 22 October, Mr Owens transferred to a different hospital. His health declined
rapidly.
31. Mr Owens died on 4 November 2022. The FLO contacted his cousin by telephone
on the same day and advised that he had died.
Post-mortem report
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 Owens’ cause of death as
bronchopneumonia related to end stage COPD and kidney failure.
Inquest
33. The inquest into Mr Owens’ death concluded on 20 March 2025 and recorded a
verdict of natural causes.
Adrian Usher
Prisons and Probation Ombudsman September 2023
4 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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