Ewan Homer

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Independent investigation into
the death of Mr Ewan Homer
a prisoner at HMP Stafford,
on 6 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
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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. Mr Ewan Homer died from adenocarcinoma of the postnasal space (cancer of the
nose and nasal area) on 6 November 2022, at HMP Stafford. He was 66 years old.
We offer our condolences to Mr Homer’s family and friends.
4. The PPO family liaison officer wrote to Mr Homer’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. He did
not respond to our letter.
5. NHS England commissioned an independent clinical reviewer to review Mr Homer’s
clinical care at HMP Stafford. She concluded that the clinical care Mr Homer
received at Stafford was not equivalent to that which he could have expected to
receive in the community because his cancer diagnosis was delayed by eight
months due to administrative errors made by the healthcare team at Stafford and
the hospital.
6. The clinical reviewer made the following three recommendations related to Mr
Homer’s death that the Head of Healthcare and Governor will want to address:
• The Head of Healthcare should establish a system to check that all
referral documentation is correct and includes all relevant information
before being submitted;
• The Head of Healthcare and the Governor must work together to ensure
that security staff always liaise with healthcare staff to acknowledge
healthcare priorities when there is not sufficient escort staff for all
planned health appointments; and
• The Head of Healthcare should liaise with the hospital to develop a
system to improve communication to ensure that changes in
appointments are communicated effectively.
7. The PPO investigator investigated the non-clinical issues relating to Mr Homer’s
care. We did not find any non-clinical issues of concern and we make no
recommendations. However, the Governor should note that when the investigator
asked to see the family liaison log which records contact between the prison and
the next of kin, the copy the prison provided only went up until 2 November 2022.
When we asked the prison for the updated log, we were told that they were unable
to locate a copy.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Prisons and Probation Ombudsman 1
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Adrian Usher February 2024
Prisons and Probation Ombudsman
Inquest into Mr Homer’s death
The inquest into Mr Homer’s death was held on 12 January 2025 and a verdict of natural
causes was recorded. The coroner concluded that Mr Homer’s death was due to high
grade adenocarcinoma of postnasal space.
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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