Paul Pesticcio

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Paul Pesticcio,
a prisoner at HMP Parc,
on 19 December 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. Mr Paul Pesticcio died of hepatocellular carcinoma (liver cancer) on 19 December
2023, at HMP Parc. He was 84 years old. We offer our condolences to Mr
Pesticcio’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Pesticcio received at HMP
Parc was equivalent to what he could have expected to receive in the community.
He commended the staff involved in Mr Pesticcio’s care as they provided an
excellent standard of palliative care to him. The clinical reviewer made
recommendations not related to Mr Pesticcio’s death that the Head of Healthcare
will wish to address.
5. We found that a prison family liaison officer (FLO) was not allocated when Mr
Pesticcio became seriously unwell. The prison did not contact Mr Pesticcio’s next of
kin until after his death.
Recommendation
The Director should ensure that a family liaison officer is allocated as soon as possible
when a prisoner becomes seriously or terminally ill, in compliance with Prison Service
Instruction (PSI) 64/2011 Managing prisoner safety in custody.
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The Investigation Process
6. HMPPS notified us of Mr Pesticcio’s death on 19 December 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr
Pesticcio’s clinical care at HMP Parc.
8. The PPO investigator investigated the non-clinical issues relating to Mr Pesticcio’s
care.
9. The Ombudsman’s office contacted Mr Pesticcio’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. They raised
concerns about Mr Pesticcio’s dietary needs, medication, general welfare, and his
application for Early Release on Compassionate Grounds. They also asked for a
copy of our report. We have addressed their concerns in our report and in the
clinical review.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
11. Mr Pesticcio’s family received a copy of the draft report. They did not make any
comments.
Previous deaths at HMP Parc
12. Mr Pesticcio was the 14th prisoner to die at HMP Parc since December 2021. Of
the previous deaths, eight were from natural causes, three were drug-related, one
was self-inflicted, and one is unascertained. Up to the end of March 2024, there has
been one natural causes death at Parc since Mr Pesticcio’s death. There are no
similarities between the findings in our investigation into Mr Pesticcio’s death and
the findings from our investigations into the previous deaths.
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Key Events
13. In December 2017, Mr Paul Pesticcio was sentenced to 16 years imprisonment for
committing sexual offences. He was sent to HMP Stafford.
14. Mr Pesticcio had several documented health conditions including type 2 diabetes
mellitus, hypertension, hypercholesterolaemia, atrial fibrillation, heart failure, and
visual impairment. He was receiving appropriate treatment for these conditions.
15. On 18 May 2023, prison officers escorted Mr Pesticcio to a hospital appointment
where he was diagnosed with primary liver cancer. He was told that due to his
general health he was not suitable for treatment.
16. In June, prison staff at Stafford started an application for Early Release on
Compassionate Grounds (ERCG). The application was not completed as Mr
Pesticcio transferred to another establishment. This meant a new ERCG application
would need to be started at Mr Pesticcio’s next establishment.
17. On 24 July, Mr Pesticcio was transferred to HMP Parc so that he could be closer to
his family to receive visits.
18. A healthcare support worker saw Mr Pesticcio for a first reception health screen and
undertook a comprehensive assessment to determine his physical, mental and
social needs.
19. On 26 July, a doctor at the prison saw Mr Pesticcio for a second reception health
screen where he confirmed the medications prescribed and illnesses. The doctor
noted that Mr Pesticcio had a cataract in his left eye, was blind in his right eye, had
a speech impediment and was deaf in his right ear, in addition to being a wheelchair
user. He referred Mr Pesticcio to the speech and language therapists for
assessment and to the palliative care specialist service.
20. On 4 August, a speech and language therapist conducted a review with Mr
Pesticcio. There was a clear, well documented plan for him to continue fluids with a
straw and recommendations for his diet.
21. On 8 August, the palliative care nursing team discussed Mr Pesticcio’s care wishes
with him.
22. Prison and healthcare staff at Parc considered starting a new ERCG application,
but decided not to proceed as they did not have a clear prognosis of life expectancy
from a healthcare specialist (a requirement of the application).
23. On 18 August, Mr Pesticcio said that he did not want anyone to resuscitate him if
his heart or breathing stopped and signed a Do Not Attempt Cardiopulmonary
Resuscitation (DNACPR) order to that effect.
24. At 10.18am on 19 December, a Prison Custody Officer discovered Mr Pesticcio
unresponsive in his cell. He attempted to wake him, but after checking his pulse
realised that Mr Pesticcio had died (he was aware that Mr Pesticcio had a DNACPR
order in place). He left the cell and went to inform an Operational Manager (OM).
He and the OM returned to Mr Pesticcio’s cell at 10.20am and called a Code Blue.
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25. A nurse attended Mr Pesticcio’s cell at 10.22am and an ambulance was stood down
due to there being a DNACPR in place. The prison doctor certified Mr Pesticcio’s
death at 11.50am.
Post-mortem report
26. The coroner accepted the cause of death provided by a prison doctor and no post-
mortem examination was carried out. The doctor gave Mr Pesticcio’s cause of
death as hepatocellular carcinoma (liver cancer). Mr Pesticcio also had heart
failure, which contributed to but did not cause his death.
27. At the inquest held on 13 August 2024, the Coroner concluded that Mr Pesticcio
died of natural causes.
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Non-Clinical Findings
Liaison with Mr Pesticcio’s family
28. Prison Service Instruction (PSI) 64/2011, about 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.
29. Although Mr Pesticcio received his terminal diagnosis in May 2023, the prison did
not appoint a family liaison officer until after his death, on 19 December 2023. This
meant that Mr Pesticcio’s wife did not have a named contact at the prison with
whom she could share her concerns with. We make the following recommendation:
The Director should ensure that a family liaison officer is allocated as soon as
possible when a prisoner becomes terminally or seriously ill, in compliance
with Prison Service Instruction (PSI) 64/2011 Managing prisoner safety in
custody.
Adrian Usher
Prisons and Probation Ombudsman September 2024
Prisons and Probation Ombudsman 5
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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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