Sean Revere

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Sean Revere,
a prisoner at HMP/YOI Moorland
on 26 August 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 16 January 2024, Mr Sean Revere was sentenced to 13 years imprisonment for
sexual offences.
4. Mr Revere died of bilateral pneumonia (an infection in both lungs) and pleural
effusions (a build-up of excess fluid around the lung) on 26 August 2024, while a
prisoner at HMP/YOI Moorland. He was 86 years old. We offer our condolences to
Mr Revere’s family and friends.
5. The Ombudsman’s office wrote to Mr Revere’s next of kin to explain the
investigation and to ask if they had any matters, they wanted us to consider. They
had no questions but asked for a copy of our report.
6. NHS England commissioned an independent clinical reviewer to review Mr
Revere’s clinical care at HMP/YOI Moorland.
7. The clinical reviewer concluded that the clinical care Mr Revere received at
Moorland was of a reasonable standard and partially equivalent to what he could
have expected to receive in the community. She noted that Mr Revere was
appropriately referred to healthcare professionals for mobility issues and to the
hospital. She concluded that escalation of NEWS2 scoring (a national tool to
monitor clinical deterioration), care planning, falls risk and post risk management
was not equivalent. The clinical reviewer made recommendations not related to Mr
Revere’s death that the Head of Healthcare will wish to address.
8. The PPO investigator investigated the non-clinical issues relating to Mr Revere’s
care.
9. We did not find any non-clinical issues of concern. We make no recommendations.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Revere’s family received a copy of the initial report. They had no questions.
12. At the inquest held on 17 April 2025, the coroner concluded that Mr Sean
Humphrey Revere died of natural causes.
Adrian Usher February 2025
Prisons and Probation Ombudsman
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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