Michael Davies

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Independent investigation into
the death of Mr Michael Davies,
a prisoner at HMP Rye Hill,
on 15 January 2025
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, 2026
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. On 5 March 2004, Mr Michael Davies was sentenced to life in prison for the rape of
a child. He died of a ruptured atherosclerotic abdominal aortic aneurysm (where
blood leaks from a major artery) on 15 January 2025, while a prisoner at Rye Hill.
He was 70 years old. We offer our condolences to Mr Davies’ family and friends.
4. The Ombudsman’s office wrote to Mr Davies’ 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 Davies’
clinical care at HMP Rye Hill.
6. The PPO investigator investigated the non-clinical issues relating to Mr Davies’
care.
7. As part of the investigation, the clinical reviewer and PPO investigator interviewed
two members of healthcare staff on 14 March 2025.
8. The clinical reviewer concluded that the clinical care that Mr Davies received at Rye
Hill was of a reasonable standard and was equivalent to that which he could have
expected to receive in the community. The clinical reviewer made three
recommendations about Mr Davies’ death which the Head of Healthcare will need
to address.
9. We did not identify any non-clinical learning.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Good practice
11. The family liaison officers at Rye Hill were concerned about the welfare of Mr
Davies’ next of kin and appropriately reported their concerns to social services.
Adrian Usher
Prisons and Probation Ombudsman August 2025
Prisons and Probation Ombudsman 1
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Inquest
12. The inquest into Mr Davies’ death was held on 27 July 2026 and a verdict of natural
causes was recorded. The coroner concluded that Mr Davies’ death was due to a
ruptured atherosclerotic abdominal aortic aneurysm.
2 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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