Nathan Walters

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Independent investigation into
the death of Mr Nathan Walters,
a prisoner at
HMP Lancaster Farms,
on 22 April 2023
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
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Summary
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 22 April 2023, Mr Nathan Walters died in a hospice of disseminated cancer,
caused by colon cancer, while a prisoner at HMP Lancaster Farms. He was 37
years old. We offer our condolences to Mr Walters’ family and friends.
4. The clinical reviewer concluded that the clinical care Mr Walters received at HMP
Lancaster Farms was of a good standard and equivalent to that which he could
have expected in the community. The clinical reviewer made no recommendations.
Good practice
5. The clinical reviewer identified good practice in the healthcare team visiting Mr
Walters while he was in hospital and in their commitment to attending
multidisciplinary meetings after Mr Walters’ transfer to HMP Preston.
Non-clinical findings
6. Mr Walters was not allocated a family liaison officer until 15 February 2023, despite
him becoming seriously ill on 10 October 2022. Subsequently, Lancaster Farms did
not notify Mr Walters’ family of his condition until 15 February.
Recommendation
• The Governor should ensure that a family liaison officer is appointed when a
prisoner becomes seriously ill and that appropriate arrangements are made to
ensure early contact with families.
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The Investigation Process
7. HMPPS notified us of Mr Walters’ death on 22 April 2023.
8. NHS England commissioned an independent clinical reviewer to review Mr Walters’
clinical care at HMP Lancaster Farms.
9. The PPO investigator investigated the non-clinical issues relating to Mr Walters’
care.
10. The PPO family liaison officer wrote to Mr Walters’ next of kin, his sister, to explain
the investigation and to ask if she had any matters she wanted us to consider. She
asked for a copy of our investigation report. She was concerned about Mr Walters’
healthcare and the lack of communication from Lancaster Farms about his illness.
She did not give us further information about this.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
12. Mr Walters’ family received a copy of the draft report. They did not make any
comments.
Previous deaths at HMP Lancaster Farms
13. Mr Walters was the third prisoner to die at HMP Lancaster Farms since 22 April
2020. All the deaths were from natural causes. There are no similarities between
the findings in our investigation into Mr Walters’ death and the findings from our
investigations into the previous deaths. Up to the end of 2023, there has been one
further death, which is awaiting classification.
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Key Events
14. On 4 May 2012, Mr Nathan Walters received an Imprisonment for Public Protection
(IPP) sentence of five years and seven months for robbery and assaults with intent
to rob.
15. On 27 May 2022, Mr Walters was transferred from HMP Kirkham to HMP Lancaster
Farms.
16. On 27 June, a GP operating at Lancaster Farms saw Mr Walters because he was
breathless. Mr Walters refused to have a blood test because he did not like
needles. She explained to Mr Walters that it was his choice, but she could not
investigate the cause without a blood test.
17. On 6 September, a paramedic at Lancaster Farms saw Mr Walters because he felt
weak, dizzy and breathless. He asked for an urgent GP review. A GP operating at
Lancaster Farms reviewed Mr Walters and told him that he needed to have urgent
blood tests. Mr Walters agreed on this occasion.
18. On 7 September, Mr Walters was admitted to hospital as his blood test results
indicated that he had severe anaemia (a condition where the number of red blood
cells is lower than normal). Mr Walters told a nurse that he did not want his family to
be informed about his health at that time. Mr Walters had a blood transfusion and
was diagnosed with a malignant tumour in the bowel and a pulmonary embolism (a
blood clot blocking a vessel in the lungs).
19. On 15 September, Mr Walters had surgery to remove the tumour.
20. On 20 September, Mr Walters was discharged to Lancaster Farms.
21. On 22 September, Mr Walters told a GP operating at Lancaster Farms that he had
not told his family about the tumour as he wanted to see what treatment the
oncologist recommended.
22. On 10 October, a nurse contacted the hospital, who advised that Mr Walters’
tumour was advanced and had spread. They told her that Mr Walters needed
chemotherapy to manage the cancer.
23. On 11 October, a multidisciplinary meeting took place to discuss Mr Walters’
condition. A care plan was agreed to support his cancer diagnosis and
chemotherapy. A GP operating at the prison saw Mr Walters and advised him to
talk to his family about the diagnosis.
24. On 14 October, Mr Walters told his keyworker that he had talked to his family about
his illness.
25. On 1 November, Mr Walters attended a hospital appointment and started his
chemotherapy.
26. On 22 December, Mr Walters attended a hospital appointment, and he was told that
he needed palliative care for his cancer.
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27. On 7 January 2023, a nurse received an email from the colorectal specialist nurse
who stated that the cancer had spread to Mr Walters’ spine and retroperitoneal soft
tissue.
28. On 19 January, Mr Walters felt unwell and was admitted to the hospital emergency
department for urgent blood tests and a medical assessment.
29. On 22 January, Mr Walters was discharged from hospital to Lancaster Farms.
30. On 26 January, a nurse received an email from the hospital, which stated that Mr
Walters had been told that surgery was not possible, and as his condition had
progressed while undergoing chemotherapy, radiotherapy was recommended to
help Mr Walters’ symptoms.
31. On 13 February, Mr Walters was admitted to the emergency department following
abdominal pain. A palliative care nurse saw him and put in place a syringe driver.
He was given a prognosis of months. The hospital discussed a do not attempt
cardiopulmonary resuscitation (DNACPR) with his sister.
32. On 15 February, an officer was allocated as Mr Walters’ family liaison officer.
33. On 20 February, Mr Walters was transferred to another hospital to receive palliative
radiotherapy over a five-day period.
34. On 6 March, a nurse contacted the hospital, who confirmed that Mr Walters had a
DNACPR in place, and he was medically fit for discharge from hospital. As there
was no 24-hour inpatient unit at Lancaster Farms, the prison was considering a
compassionate transfer to another prison.
35. On 28 March, Mr Walters was discharged to the 24-hour inpatient unit at HMP
Preston while he waited for a hospice bed. When Mr Walters arrived at Preston, he
was in severe pain, he was vomiting and was unable to walk. He was therefore
readmitted to hospital that day for further pain assessment and management.
36. On 30 March, Lancaster Farms submitted an application for Mr Walters’ early
release on compassionate grounds to the Public Protection Casework Section
(PPCS) of HMPPS. The Secretary of State refused his application on the basis of
risk of harm to the public and insufficient evidence that imprisonment caused Mr
Walters greater suffering as he was receiving 24-hour healthcare.
37. On 6 April, Mr Walters was discharged to the inpatient unit at Preston, though
Lancaster Farms remained responsible for his care. A nurse created plans for end-
of-life, syringe driver and bowel care.
38. On 13 April, a multidisciplinary meeting was held to discuss Mr Walters. He
remained on the waiting list for a hospice bed.
39. On 19 April, Mr Walters was transferred to a hospice for end-of-life care, where he
died on 22 April. His sister was with him when he died.
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Post-mortem report
40. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Walters’ cause of death
as disseminated cancer caused by colon cancer.
Inquest
41. At an inquest held on 28 August 2025, the Coroner concluded that Mr Walters died
of natural causes.
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Non-Clinical Findings
Liaison with Mr Walters’ family
42. Prison Service Instruction (PSI) 64/2011 on safer custody says that prisons must
have arrangements in place for an appropriate member of staff to engage with the
next of kin of prisoners who are either terminally or seriously ill.
43. Mr Walters should have been assigned a family liaison officer on 10 October 2022
when he was notified that his tumour was at an advanced stage and had spread.
Lancaster Farms missed a second opportunity to contact Mr Walters’ family about
his condition when palliative care was arranged for him on 22 December 2022.
44. An officer was not appointed as Mr Walters’ family liaison officer until 15 February
2023, when she initiated contact with his next of kin. It is noted in the family liaison
contact log that his sister was in shock about the seriousness of Mr Walters’
condition.
45. From 17 February 2023 onwards, Mr Walters’ sister visited him frequently and was
at his bedside when he died. She told us in June 2023 that she was concerned
about the lack of communication from Lancaster Farms about Mr Walters’ illness.
46. While we note that Mr Walters told his keyworker that he had spoken to his family
about his illness on 14 October 2022, a family liaison officer should have been
appointed sooner to ensure Mr Walters’ family was given sufficient support and
information about his health before his death. We make the following
recommendation:
The Governor should ensure that a family liaison officer is appointed when a
prisoner becomes seriously ill and that appropriate arrangements are made to
ensure early contact with families.
Governor to note
47. While we recognise that Mr Walters’ restraints were removed due to his ill health in
hospital on 30 March 2023, Lancaster Farms was unable to locate the restraints
paperwork for Mr Walters’ escorts after this date. We were therefore unable to
establish whether he was restrained during the month before his death.
48. Lancaster Farms told us that they did not take any staff statements in relation to Mr
Walters’ death.
Adrian Usher
Prisons and Probation Ombudsman May 2024
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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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