Sean Willingale

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Sean Willingale,
a prisoner at HMP Oakwood, on
14 November 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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© 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 14 September 2022, Mr Sean Willingale was convicted of breach of a
restraining order and remanded to HMP Birmingham. On 12 October, Mr Willingale
was sentenced to 28 months in prison. Over the following year and a half, Mr
Willingale was twice released from prison and subsequently recalled for breach of
licence conditions. His final recall was on 15 April 2024, and he was transferred to
HMP Oakwood on 3 May.
4. On 14 November 2024, Mr Willingale died in hospital while a prisoner at Oakwood.
We have not been provided with a cause of death, but Mr Willingale had been
diagnosed with squamous cell carcinoma of the tongue (tongue cancer). He was 58
years old. We offer our condolences to Mr Willingale’s family and friends.
5. The Ombudsman’s office wrote to Mr Willingale’s nominated next of kin, his
probation officer, to explain the investigation and to ask if they had any matters they
wanted us to consider. They did not respond. We were contacted afterwards by
family members who asked for a copy of the initial report. One raised concerns
about Mr Willingale’s healthcare at HMP Oakwood which have been addressed in
separate correspondence.
6. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
7. NHS England commissioned an independent clinical reviewer, to review Mr
Willingale’s clinical care at Oakwood.
8. The clinical reviewer highlighted that Mr Willingale was unwell for a considerable
length of time. She noted that he was a complex man who posed significant
challenges for the professionals who cared for him, but that there was evidence of
compassionate, holistic and dynamic care from the healthcare team at Oakwood.
The clinical reviewer concluded that the clinical care Mr Willingale received at
Oakwood was of a good standard and equivalent to that which he could have
expected to receive in the community.
9. The PPO investigator investigated the non-clinical issues relating to Mr Willingale’s
care.
10. We did not find any non-clinical issues of concern. We make no recommendations.
Prisons and Probation Ombudsman 1
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11. The inquest into Mr Willingale’s death concluded on the 30 October 2025. The
coroner confirmed that Mr Willingale died of natural causes.
Adrian Usher November 2025
Prisons and Probation Ombudsman
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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