David James Hallet · Prevention of Future Deaths report

On the 12th December 2014 I commenced an investigation into the death of David James Hallet. The investigation concluded at the end of an inquest on 23rd June 2015. The conclusion of the inquest was that he died of "natural causes".

The deceased was serving a sentence of imprisonment and during a period when he was transferred to HMP Rye Hill was admitted to hospital and was later diagnosed as suffering from metastatic pancreatic cancer. He passed away on 4th December 2014 at HMP Parc – having been transferred to their palliative care suite.

• The evidence revealed that in the early part of 2014, there was a nationally designated re-roll for HMP Rye Hill which meant that it would be a designated prison to receive convicted sex offenders.

• Initial assessments undertaken during this process indicated that their Healthcare department would be adequately resourced to be able to cope with a influx of additional prisoners.

• That was clearly not the case and the standard of care received by this prisoner was found to be inadequate and certainly far below the standard he might have expected in the community.

• The evidence indicated that one of the primary reasons for this was lack of preparation by the Prison Authorities staff and an inability to cope with the types of prisoners who were transferred to HMP Rye Hill. The clinical review undertaken by Healthcare Inspectorate Wales was critical of the care he received at HMP Rye Hill and the evidence clearly indicated that a lack of preparation for the re-roll and the lack of adequate resources were the primary reason for this substandard care.

• Whilst it is appreciated that HMP Rye Hill may not be subject to a further re-roll it is of concern that other re-rolls nationally may be being considered and which may conceivably give rise to issues similar to those presented in this case.