Frederick Williams

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Independent investigation into the
death of Mr Frederick Williams,
a prisoner at HMP The Verne,
on 12 January 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
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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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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. On 10 November 2021, Mr Frederick Williams was sentenced to nine years in
prison for indecent assault. He died of peritonitis (an infection of the inner lining of
the stomach) and pneumonia (a lung infection) caused by a large bowel perforation
(a hole in the lining of the bowel) on 12 January 2024, at HMP The Verne. He was
86 years old. We offer our condolences to Mr Williams’ family and friends.
4. The Ombudsman’s office wrote to Mr Williams’ wife to explain the investigation and
to ask if she had any matters she wanted us to consider. She asked why Mr
Williams was being given palliative care when his causes of death were treatable.
5. The PPO investigator investigated the non-clinical issues relating to Mr Williams’
care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Mr
Williams’ clinical care at HMP The Verne.
7. The clinical reviewer concluded that the clinical care Mr Williams received at The
Verne was partially equivalent to that which he could have expected to receive in
the community. She found that, while there was evidence that treatment escalation
plans were discussed with Mr Williams, this could have been improved by
translating these discussions into a formal end of life/advanced care plan in line with
national guidelines.
8. The clinical reviewer made recommendations not related to Mr Williams’ death that
the Head of Healthcare will wish to address. We make two recommendations
related to his death:
The Head of Healthcare should ensure that an end-of-life register is in place at
HMP The Verne that enables early identification of those patients with
palliative care needs and to proactively plan for end-of-life care.
The Head of Healthcare should ensure that all patients who have life limiting
conditions have an advanced care plan in accordance with NICE guidelines.
9. The inquest into Mr William’ death concluded on 29 April 2025, returning a verdict of
natural causes.
Adrian Usher July 2024
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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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
OFFICIAL - FOR PUBLIC RELEASE