Lorna Carter

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Ms Lorna Carter,
a prisoner at HMP Styal,
on 27 January 2025
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, 2026
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
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 23 November 2024, Ms Lorna Carter was remanded in prison charged with drug
offences. She died in hospital of multiorgan failure (due to liver cirrhosis, heart
failure and pneumonia) on 27 January 2025, while a prisoner at HMP Styal. She
was 58 years old. We offer our condolences to Ms Carter’s family and friends.
4. The Ombudsman’s office wrote to Ms Carter’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
asked questions about Ms Carter’s healthcare which have been addressed in the
clinical review. They asked some other questions which have been addressed in
separate correspondence.
5. The PPO investigator investigated the non-clinical issues relating to Ms Carter’s
care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Ms Carter’s
clinical care at HMP Styal.
7. The clinical reviewer concluded that the clinical care Ms Carter received at Styal
was of a variable standard and only partially equivalent to that which she could
have expected to receive in the community.
8. She found that when Ms Carter discharged herself from hospital on 22 December
against medical advice, she was not seen by healthcare staff when she returned to
the prison and her clinical observations were not taken until three days later. This
meant that Ms Carter’s baseline observations were not taken (nor a NEWS2 score
calculated, a tool to assess clinical deterioration) on her return from hospital, which
would have informed the need for escalation if her condition changed. We
recommend:
The Head of Healthcare should ensure that, when a patient returns from
hospital following A&E attendance, they are reviewed and clinical
observations, including NEWS2, are taken.
9. The clinical reviewer also made recommendations not directly related to Ms Carter’s
death which the Head of Healthcare will wish to address.
10. We shared our initial report with HMPPS and the prison’s healthcare provider,
Spectrum Community Health CIC. They found no factual inaccuracies. Spectrum
Community Health CIC provided an action plan which is annexed to this report.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
11. We sent a copy of our initial report to Ms Carter’s next of kin. They did not notify us
of any factual inaccuracies.
Adrian Usher July 2025
Prisons and Probation Ombudsman
Inquest
At the inquest, held on 20 January 2026, the Coroner concluded that Ms Carter died from
natural causes.
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