Victor Todd

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Independent investigation into
the death of Mr Victor Todd,
a prisoner at HMP Moorland,
on 14 April 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
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. In January 2019, Mr Victor Todd was sentenced to 19 years imprisonment for
sexual offences. He died of lung cancer and chronic obstructive pulmonary disease
(COPD – the term for a group of serious lung diseases) on 14 April 2024, at HMP
Moorland. He was 82 years old. We offer our condolences to Mr Todd’s family and
friends.
4. The Ombudsman’s office contacted Mr Todd’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
raised concerns about Mr Todd’s clinical care in the prison and why compassionate
release had not been considered. They also raised several issues that were outside
the remit of our investigation which have been addressed through separate
correspondence.
5. NHS England commissioned independent clinical reviewers to review Mr Todd’s
clinical care at Moorland.
6. The clinical reviewers concluded that the clinical care Mr Todd received at Moorland
was of a very good standard and equivalent to that which he could have expected
to receive in the community.
7. The PPO investigator investigated the non-clinical issues relating to Mr Todd’s care.
We note that the prison did not apply for Mr Todd’s early release on compassionate
grounds (ERCG). This was because, as part of his end-of-life care planning, Mr
Todd had expressed his wish to die at Moorland, surrounded by prisoners and staff
with whom he was familiar. We consider it was appropriate for the prison not to
apply for ERCG in the circumstances.
8. We make no recommendations.
9. We shared our initial report with HMPPS and with the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies.
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10. We sent a copy of our initial report to Mr Todd’s next of kin. They disputed that Mr
Todd had said he wanted to die in prison. The clinical reviewer checked the clinical
records and found no evidence that Mr Todd had ever said that he wanted to be
released to die. The ReSPECT form, which records a person’s wishes about their
healthcare, said that he wanted to die in his own familiar environment. It also
recorded that Mr Todd had the mental capacity to make that decision. Mr Todd’s
next of kin raised some other issues about his medical history, which have been
addressed in separate correspondence.
Adrian Usher
Prisons and Probation Ombudsman November 2024
Inquest
The inquest, held on 17 January 2025, concluded that Mr Todd died from natural causes.
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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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