Aaron Harte

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Aaron Harte, a
prisoner at HMP Peterborough,
on 3 November 2022
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© 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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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.
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.
Mr Aaron Harte died from synthetic cannabinoid toxicity on 3 November 2022 at HMP
Peterborough. He was 35 years old. I offer my condolences to Mr Harte’s family and
friends.
Peterborough has some robust measures in place to deter and detect illicit drugs entering
the prison, but Mr Harte was still able to obtain psychoactive substances, which proved
fatal. The most recent reports from His Majesty’s Chief Inspector of Prisons and from the
Independent Monitoring Board indicated that there had been some successes in reducing
the entry of drugs into the prison. Peterborough should continue to prioritise and develop
their drug strategy.
The clinical reviewer concluded that the healthcare Mr Harte received at Peterborough
was of a good standard and equivalent to that which he could have expected to receive in
the community.
While we make no formal recommendations, we bring a number of issues to the Director’s
attention.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman October 2023
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 2
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 16 February 2022, Mr Harte was remanded to HMP Peterborough charged with
stalking.
2. On his arrival at Peterborough, healthcare staff completed an initial health screen.
They identified that Mr Harte needed alcohol detoxification. He also said that he had
used cannabis and crack cocaine, although urine test results were negative. Mr
Harte said that he had no thoughts of suicide or self-harm.
3. On 5 July, Mr Harte was released from court and was required to comply with the
terms of a conditional licence. On 7 September, he was recalled to prison after
breaching his licence conditions. He was sent back to HMP Peterborough.
4. When he arrived, Mr Harte started an alcohol detoxification programme, which
lasted until 15 September. Staff from the substance misuse team at Peterborough
offered him additional support but he declined. Prison and healthcare staff did not
raise any concerns about Mr Harte’s custodial behaviour or that he was using or
involved with illicit drugs.
5. At around 4.30am on 3 November, two prison officers began to complete the
morning routine check. When one of the officers checked on Mr Harte, he was
concerned that Mr Harte was lying in an unusual position. The officer stood at the
door and waited to see if Mr Harte would move, but he did not. The officer asked
the duty manager to attend the cell.
6. When the staff entered the cell, Mr Harte was unresponsive and cold, and it was
clear he was dead. Nevertheless, prison and nursing staff started cardiopulmonary
resuscitation (CPR). The paramedics confirmed that Mr Harte had died.
Findings
7. Mr Harte was able to source and use illicit drugs, which caused his death.
8. Peterborough has taken some steps to address its drug supply issues, but Mr
Harte’s death is a reminder that there is always more to be done to reduce the
availability and detection of drugs. The availability of illicit substances remains a
problem across the whole prison estate and should remain a priority for
Peterborough.
9. The clinical reviewer concluded that the healthcare Mr Harte received was of a
good standard and equivalent to that which he could have expected to receive in
the community.
10. The night staff did not enter his cell or radio a code blue emergency when they
found Mr Harte unresponsive.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
11. HM Prison and Probation Service notified us of Mr Harte’s death on 3 November
2022.The investigator issued notices to staff and prisoners at HMP Peterborough
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Harte’s prison and
medical records.
13. The investigator interviewed seven members of staff at HMP Peterborough on 22
December.
14. NHS England commissioned a clinical reviewer to review Mr Harte’s clinical care at
the prison.
15. We informed HM Coroner for Cambridgeshire of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
16. The Ombudsman’s family liaison officer contacted Mr Harte’s mother, to explain the
investigation and to ask if she had any matters, she wanted us to consider. Mr
Harte’s mother said that she had no questions at that time. The family were sent a
copy of our initial report, but no response to our findings was received.
17. An inquest into Mr Harte’s death was opened on 16 November 2022 and concluded
on 16 September 2025. A jury concluded that Mr Harte died as a result on synthetic
cannabinoid toxicity.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Peterborough
18. HMP/YOI Peterborough is operated by Sodexo Justice Services. It holds men and
women in separate sides of the prison. There is 24-hour healthcare provision. All
healthcare is provided by Sodexo under the provisions of their contract with the
Ministry of Justice.
HM Inspectorate of Prisons
19. The most recent full inspection of HMP/YOI Peterborough men’s prison was a
scrutiny visit in November 2020. Inspectors concluded that, despite some staffing
difficulties, the integrated substance misuse service had been providing good
clinical and psychosocial support, with regular face-to-face assessments and joint
reviews. There had been a good flow of local intelligence which was being analysed
effectively, and the prison was addressing emerging risks, such as the entry of
drugs.
Independent Monitoring Board
20. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to March 2022, the IMB reported
that it was encouraged by the impact that security measures had had in reducing
the flow of illicit substances into the prison. The IMB reported that all incoming
personal mail for prisoners was photocopied to prevent any impregnated with drugs
from reaching the wings. Parcels that were sent to the prison were checked by dogs
and if necessary screened for drugs. Airport-style security was introduced in May
2021 for all staff and visitors, including X-ray scanning, and the prison used
transparent bags for staff possessions and searches.
Previous deaths at HMP Peterborough
21. Mr Harte was the fourteenth prisoner to die at Peterborough since May 2019. Of the
previous deaths, two were self-inflicted, ten were from natural causes and one was
drug related. In a previous investigation into the drug related death of a prisoner in
2021, we noted that the prison must continue to develop strategies to reduce the
supply and demand of illicit drugs in Peterborough.
Psychoactive Substances (PS)
22. PS (formerly known as ‘legal highs’) continue to be a serious problem across the
prison estate. They can be difficult to detect and can affect people in a number of
ways, including increasing heart rate, raising blood pressure, reducing blood supply
to the heart and vomiting. Prisoners under the influence of PS can present with
marked levels of disinhibition, heightened energy levels, a high tolerance of pain
and a potential for violence. Besides emerging evidence of such dangers to
physical health, the use of PS is associated with the deterioration of mental health,
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
suicide and self-harm. Testing for PS is in place in prisons as part of existing
mandatory drug testing arrangements.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
23. On 16 February 2022, Mr Harte was remanded to HMP Peterborough charged with
stalking.
24. When Mr Harte arrived at Peterborough, healthcare staff completed an initial health
screen. Mr Harte told nursing staff that he used illicit drugs including cannabis and
crack cocaine, but urine test results were negative for any substances. Nursing staff
identified that Mr Harte needed alcohol detoxification. He said that he suffered with
anxiety, depression, and paranoia. Healthcare staff referred him to the mental
health team. He was later assessed and prescribed appropriate medication and
was monitored regularly. Mr Harte said that he had no thoughts of suicide or self-
harm.
25. On 5 July, Mr Harte appeared in court and was served with a restraining order. Due
to time he had already served in prison on remand, he was released from court on a
conditional licence.
26. On 7 September, Mr Harte was recalled to prison after he had breached the
conditions of his licence. He was sent back to HMP Peterborough.
27. When Mr Harte arrived at Peterborough, healthcare staff completed another initial
health screen and a drug test, and the results showed that Mr Harte had used
diazepam. Mr Harte said that he was prescribed this medication for alcohol
detoxification while he was in police custody. He said that he had not used any
other illicit drugs. Nursing staff referred him to the alcohol intervention service and
the mental health team.
28. Mr Harte started an alcohol detoxification programme, which he completed on 15
September. Nursing staff saw him daily and staff from the substance misuse team
monitored him during the night.
29. On 12 September, a nurse reviewed Mr Harte’s mental health referral and offered
him an assessment at the clinic.
30. On 20 September, a worker from the substance misuse team saw Mr Harte and
offered him additional support, but he declined the offer.
31. A Prison Custody Officer (PCO) completed keyworker sessions with Mr Harte
between September and October. During these sessions, Mr Harte said that he had
settled on the wing and was coping well. He felt safe and raised no other issues.
32. Mr Harte asked another PCO about his release date, and the PCO confirmed that
he was due for release on 21 November. Mr Harte told the PCO that he would like
to work while in prison, but he started to feel stressed when he struggled to secure
a job on the wing. Mr Harte told the PCO that he felt that having a job would help
him resolve some of his mental health issues.
33. Mr Harte later secured a job in the prison kitchen, which meant that he was out of
his cell for most of the day and this made him happy. He said that he was making
preparations for his release and was in contact with his family.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
34. On the night of 2 November, two Operational Support Officers (OSO) were both on
night duty. At around 10.30pm, they completed a routine check of all prisoners on
the wing. OSO A had checked Mr Harte’s cell and he was not concerned about him.
He said that Mr Harte was sat on his bed.
Events of 3 November
35. At around 4.30am on 3 November, both OSOs began completing the first routine
check of the morning. When OSO B reached Mr Harte cell, he looked through the
observation panel and thought that Mr Harte was lying in a strange position. He said
that he could not imagine himself lying like that and that he thought it would not be
comfortable. Mr Harte was lying on his side, with his head towards the window (at
the back of the cell) looking downwards. One of Mr Harte’s hands and his legs were
hanging off the bed, and his back was facing the door.
36. OSO B waited to see if Mr Harte moved, but he did not. He called OSO A across to
ask what he thought, and they both stood at the door and tried to listen for any
sounds of breathing. They knocked on the door and flashed their torches into the
cell, but Mr Harte did not respond. OSO B said that he and OSO A felt that they
needed to check on Mr Harte, so he radioed for the night manager to attend the
wing.
37. A Senior Prison Custody Officer (SPCO) was the duty night manager. He
telephoned the wing and spoke to OSO B, who said that they could not get a
response from Mr Harte. The SPCO did not instruct them to go into the cell.
38. At approximately 4.35am, the SPCO arrived at the wing and saw other staff outside
the cell including the deputy night manager. The staff entered the cell. Mr Harte’s
body was twisted, and he was lying face down on the duvet. The SPCO called to Mr
Harte, but he did not respond. He then shook his arm. He said that Mr Harte felt
very cold, and his body was rigid. When he turned Mr Harte over, his first thought
was that he had died as there were clear signs of rigor mortis. Staff moved Mr Harte
onto the floor and began CPR. The SPCO radioed a code blue at 4.36am.
39. At approximately 4.40am, nursing staff arrived at the cell and took over
resuscitation attempts. Paramedics arrived, and at 4.48am, they confirmed that Mr
Harte had died.
Events following Mr Harte’s death
40. Prison managers informed the police of Mr Harte’s death and they attended the
prison. Prison staff told the police that Mr Harte had a history of illicit drug use. The
police searched Mr Harte’s cell and seized a number of items, including a vape pen
and two orange tablets, to be tested for illicit drugs.
41. In a statement to the Coroner, the police said that that when they attended the
prison on the day of Mr Harte’s death, they were made aware that another prisoner
on the same wing was suffering from what was believed to be an illicit drug-induced
seizure caused by a suspected psychoactive substance. Prison staff conducted a
search of the wing and found a herbal substance known as ‘Pandora’s Box’ which is
known to have strong effects. Prison staff notified the police.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
42. The police did not confirm whether the items seized from Mr Harte’s cell were
tested. However, Mr Harte was prescribed medication which he was required to
take under supervision by nursing staff, therefore it is likely that the two orange
tablets found in his cell were illicitly obtained.
Contact with Mr Harte’s family
43. A chaplain was appointed as the prison’s family liaison officer (FLO). Mr Harte had
a close relative also at Peterborough. The prison was concerned that Mr Harte’s
mother might learn of his death from another prisoner and concluded that they
needed to act swiftly. The FLO called Mr Harte’s mother on the morning of 3
November and broke the news of Mr Harte’s death and offered his condolences. He
remained in contact with Mr Harte’s mother and updated her on the process that
would follow.
44. The prison offered a contribution to funeral costs in line with Prison Service policy.
Support for prisoners and staff
45. Prison managers debriefed the staff involved in the emergency response to ensure
they had the opportunity to discuss any issues arising, and to offer support. The
staff care team also offered support.
46. The majority of those staff interviewed and that had been involved in the events on
3 November told the investigator that they felt that there was a lack of support
offered on the day and that there was little or no follow up care provided for them.
47. The prison posted notices informing other prisoners of Mr Harte’s death and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by the death.
Post-mortem report
48. The post-mortem report gave Mr Harte’s cause of death as synthetic cannabinoid
toxicity.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Drug strategy at HMP Peterborough
49. Mr Harte died of synthetic cannabinoid toxicity (the toxic effects of illicit PS use).
Clearly, he was able to obtain illicit drugs at Peterborough, despite the prison’s best
efforts to reduce drug supply and demand. We have not identified any evidence to
suggest that either the prison or the police established where or when Mr Harte
obtained the PS.
50. At the last HMIP inspection in 2022, inspectors reported that there had been some
success in reducing the entry of drugs to the prison, a good flow of local intelligence
was being analysed effectively, and the prison was addressing emerging risks, such
as the entry of drugs. This was a view shared by the IMB, who found that there
were robust procedures in place, including that all incoming personal mail for
prisoners was photocopied to prevent any impregnated with drugs from reaching
the wings. Parcels sent in were checked by dogs and if necessary, screened for
drugs. Airport-style security was introduced in May 2021 for all staff and visitors,
including X-ray scanners and transparent bags for staff possessions and searches.
The IMB indicated that good progress had been made.
51. We acknowledge the difficulty in preventing drugs entering the prison. PS is
especially prevalent. Peterborough has a large perimeter and is situated in an open
and accessible area vulnerable to ‘throw-overs’ and drones. The illicit drugs market
in prison is usually controlled by organised crime gangs and the scale of the
problem requires a co-ordinated approach. Although it is clear that some things are
being done very well at Peterborough, including the analysis of intelligence and the
system for checking the validity of legal mail, the threat from drugs is constantly
evolving and more can always be done.
52. We were told that Peterborough has not yet requested a review of their drug
strategy by HMPPS Substance Misuse Group. The Director should consider
whether a full diagnostic review of the prison’s drug strategy, including any potential
areas of weakness in the prison’s efforts to reduce supply, would be helpful.
Mr Harte’s substance misuse support
53. When Mr Harte arrived in prison, he said that he had a history or illicit drug use but
he only tested positive for diazepam, which he had been prescribed in police
custody. Mr Harte completed an alcohol detoxification programme in September
2022. Staff from the prison’s substance misuse team offered him additional support,
but he declined the offer.
54. Staff raised no concerns about Mr Harte being involved in the use or supply of illicit
drugs and had recorded no concerns about him being under the influence of illicit
substances during his time at Peterborough.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Clinical care
55. The clinical reviewer concluded that the healthcare that Mr Harte received was of a
good standard and was equivalent to that which he could have expected to receive
in the community.
56. She found that healthcare staff completed appropriate medication reviews for his
alcohol withdrawal. He was reviewed regularly and received on-going support for
his mental health.
Emergency response
57. Prison Service Instruction (PSI) 24/2011 gives national guidance for entering cells
at night. The PSI says that under normal circumstances, the night orderly officer
must give authority to unlock a cell at night and a cell opened with a minimum
number of staff (according to local risk guidelines) present. However, the PSI goes
on to say, that the preservation of life must take precedence over this. Where there
is or appears to be threat to life, staff may open and enter cells on their own if they
feel safe to do so, having performed a dynamic risk assessment and informed the
control room.
58. The investigator asked the SCO about the procedures for unlocking a cell during
the night state. The SCO said that if a member of staff deemed it necessary to call a
medical emergency code, or they thought that there was a serious risk to life, they
could enter the cell without waiting for the duty manager or other staff to arrive.
59. The two OSOs on duty were not sure whether Mr Harte was okay and did not
consider there was immediate cause for concern. OSO B said that, had he
considered there was immediate risk to life, he would have gone into the cell. When
the deputy night manager arrived, about one to two minutes before the SCO, Mr
Harte was still unresponsive. We consider that, at this point, with three staff present
(one of whom was the deputy night manager), the SCO should have unlocked and
entered the cell.
60. The Director should consider how he can support his staff, particularly those in
senior roles, to make swift, confident decisions in uncertain situations.
Director to note
Resuscitation
61. Resuscitation Council (UK) guidelines state that staff should consider whether CPR
efforts would be successful and, in the patient’s, best interests. The guidelines state
that, “resuscitation is inappropriate and should not be provided when there is clear
evidence that it will be futile”. The guidelines define examples of futility as including
the presence of rigor mortis. Rigor mortis normally sets in between two and six
hours after death, indicating that Mr Harte had been dead for some time when he
was found.
62. We understand the wish to continue resuscitation until death has been formally
recognised but trying to resuscitate someone who is clearly dead is distressing for
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
staff and undignified for the deceased. The guidance highlights that resuscitation is
inappropriate and should not be provided when there is clear evidence that it will be
futile. The guidelines give examples of futility as including the presence of rigor
mortis. Staff should be given clear guidance about the circumstances in which
resuscitation is inappropriate in line with the Resuscitation Council Guidelines.
Staff support
63. During interviews with staff, most said that they did not feel that they had been
offered adequate support following Mr Harte’s death, and in some cases support
was not provided at all, other than attending the de-brief. The impact on staff who
are involved either directly or even indirectly with a death in custody can be
traumatic, and for their well-being they should be supported, be given the
opportunity to raise concerns and receive help where needed.
64. We bring these learning points to the Director and the Head of Healthcare’s
attention.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
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