Peter Honnor

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Independent investigation into
the death of Mr Peter Honnor,
a prisoner at HMP Wandsworth,
on 27 June 2024
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 Peter Honnor died of myocarditis (inflammation of the heart muscle making it
harder for the heart to pump blood around the body) on 27 June 2024, while a
prisoner at HMP Wandsworth. He was 55 years old. I offer my condolences to Mr
Honnor’s family and friends.
4. Mr Honnor had a complex medical history of heart disease, and was prescribed a
range of medications for these when he was sent to Wandsworth in May 2024.
During his short time in prison, Mr Honnor experienced at least three falls and
healthcare staff identified other emerging clinical concerns, including low blood
sodium levels (which might indicate exacerbated heart disease).
5. At around 4.18am on 27 June, Mr Honnor’s cellmate alerted the night patrol officer
that he was not breathing. The night patrol did not immediately radio a medical
emergency and told us that he could not immediately enter the cell as he was not
carrying a (mandatory) cell key in a sealed pouch. Other officers, followed by
healthcare staff, arrived and began cardiopulmonary resuscitation, but paramedics
later confirmed that Mr Honnor had died.
6. Following Mr Honnor’s death, London Ambulance Service paramedics who
attended the resuscitation identified concerns with the quality of resuscitation
undertaken by prison and healthcare staff.
7. The clinical reviewer identified concerns with how the emergency response and
other clinical events were managed and concluded that the clinical care Mr Honnor
received at Wandsworth was not equivalent to that which he could have expected to
receive in the community.
Recommendations
• The Head of Healthcare should ensure that staff understand and follow NICE
guidelines for the management of head injuries and develop a protocol so that
prisoners prescribed anticoagulants have a formal medical assessment after a head
injury including recording a clear decision around the need for CT scanning.
• The Head of Healthcare, alongside doctors involved in Mr Honnor’s care, should
undertake a formal significant event analysis to identify weaknesses in the care
provided and learning from these, and share these with all clinicians working in the
prison.
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• The Governor and Head of Healthcare should investigate the concerns raised by
London Ambulance Service paramedics, identify any learning and develop an action
plan for improvement for individual staff as required.
• The Governor should conduct a local investigation into the events of 27 June 2024,
identify and share any learning with staff and the Ombudsman, and ensure that
night patrol officers understand the equipment they are required to carry, when and
how to use it, and how to properly communicate a medical emergency.
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The Investigation Process
8. We were notified of Mr Honnor’s death on 27 June 2024.
9. The investigator issued notices to staff and prisoners at HMP Wandsworth informing
them of the investigation and asking anyone with information to contact her. One
prisoner responded, who the investigator and the clinical reviewer interviewed.
10. The investigator obtained copies of relevant extracts from Mr Honnor’s prison and
medical records.
11. NHS England commissioned an independent clinical reviewer to review Mr
Honnor’s clinical care at the prison.
12. The investigator and clinical reviewer interviewed five members of healthcare staff
and one member of prison staff on 17 September and 14 and 16 October. The
investigator interviewed two members of prison staff via video conference on 18
September and 3 October respectively.
13. We informed HM Coroner for Inner West London of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
14. The Ombudsman’s office contacted Mr Honnor’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
raised no concerns but asked for a copy of the report.
15. We also shared the initial report with Mr Honnor’s family. They did not make any
comments.
16. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Wandsworh
17. Mr Honnor was the 20th prisoner to die at Wandsworth since the end of June 2021.
Of the previous deaths, six were from natural causes, ten were self-inflicted, and
three drug related. To the end of November 2024, there has been one more self-
inflicted death at Wandsworth. There are no significant similarities between our
findings in the investigation into Mr Honnor’s death and our investigation findings for
the previous deaths.
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Key Events
18. On 6 May 2024, Mr Peter Honnor was remanded in custody to HMP Wandsworth
for threatening a person with a blade or sharply pointed article in a public place. It
was his first time in prison. At the reception health screening, a nurse identified that
Mr Honnor had a history of heart attacks and heart failure and arranged for him to
see the GP. Mr Honnor had his medications ‘in possession’ (holding and taking his
own medication). These included amlodipine, bisoprolol, ramipril and furosemide (all
for high blood pressure), atorvastatin (for high cholesterol), edoxaban (an
anticoagulant to prevent blood clots) and sertraline (an antidepressant). He also had
GTN spray, which is used to stop chest pain during angina attacks.
19. On 8 May, healthcare staff assessed Mr Honnor after he experienced chest pain.
They took Mr Honnor’s clinical observations, which were within the normal range.
Mr Honnor had an electrocardiogram (ECG) and no abnormality was detected. He
told the nurse that he was starting to feel better and that the pain was easing. The
nurse made an appointment for Mr Honnor to see a GP.
20. On 9 May, healthcare staff saw Mr Honnor in the long-term conditions clinic. He was
examined for coronary heart disease, hypertension (high blood pressure), and
chronic obstructive pulmonary disease (COPD, a group of lung conditions that
cause breathing difficulties). Healthcare staff recorded that his observations were
within an acceptable range but were a little hypotensive (indicative of low blood
pressure).
21. On 21 May, a nurse visited Mr Honnor after an officer reported that he had fallen in
his cell. Mr Honnor denied hitting his head, and there was a small graze to his
elbow and thigh. He told the nurse he had got up to change the television channel,
felt dizzy and fell. Mr Honnor said he had experienced previous dizzy spells. The
nurse took Mr Honnor’s blood pressure, which was low. The nurse liaised with a GP
at Wandsworth, due to Mr Honnor’s blood pressure reading. The GP reassured the
nurse that Mr Honnor was already booked into the GP clinic in two days. The nurse
started a falls assessment questionnaire, but there is no record that this was
completed.
22. On 23 May, prison staff found Mr Honnor collapsed in his cell. Mr Honner said that
he had got up from the chair, felt dizzy and fell down hitting his head. He denied any
loss of consciousness. Healthcare staff took Mr Honnor’s clinical observations,
which were in the normal range other than low blood pressure. They ensured he
was able to get himself up and on the bed. They encouraged Mr Honnor to take
fluids.
23. On the same day, a GP at the prison reviewed Mr Honnor (while visiting his
cellmate). He noted low serum sodium (sodium in the blood), completed an
examination that was normal, but noted Mr Honnor’s low blood pressure reading.
The GP’s impression was that Mr Honnor was overmedicated and the low sodium
and low blood pressure could be a consequence of this. He advised that Mr Honnor
stop some of his medications (furosemide and amlodipine).
24. A GP at the prison also saw Mr Honnor as part of the planned review. Her advice
and plan were the same as that proposed by the previous GP. She also noted that
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Mr Honnor asked to increase his dose of sertraline and decided to defer doing this
as sertraline can be a cause of hyponatremia (low blood sodium). Mr Honnor was
later admitted to the prison healthcare unit, where his blood pressure was monitored
twice a day.
25. On 30 May, a GP at the prison advised fluid restriction for Mr Honnor. He said that
apart from slightly low blood pressure with a persisting postural drop (drop in blood
pressure when standing after sitting/lying down), Mr Honnor had no symptoms and
was settled on the unit.
26. On 3 June, a GP at the prison noted that Mr Honnor still had a postural drop in his
blood pressure. He reduced the dose of ramipril and bisoprolol.
27. On 9 June, healthcare staff reported that Mr Honnor engaged well and, although he
had some dizziness, his health had improved and he had not reported any falls.
Healthcare staff had a care plan in place for Mr Honnor, that included the provision
of care for heart disease and high blood pressure. The plan instructed healthcare
staff to refer Mr Honnor to the GP if they identified any concerns or complications.
28. On 11 June, Mr Honnor was seen in the ECG (electrocardiogram) clinic due to a
low heart rate. A GP at the prison reviewed the results, and there were no concerns.
29. Mr Honnor remained on the prison healthcare unit where he had twice daily clinical
measurements, and nurses described him as being well with no symptoms other
than low blood pressure.
30. On 18 June, Mr Honnor asked healthcare staff for an appointment as he said he still
felt dizzy when walking up stairs and felt like he was going to pass out. He was
added to the GP waiting list for 25 June.
31. On 22 June, prison staff called a medical emergency code blue for Mr Honnor, who
reported that he had got up from bed to use the toilet, felt dizzy, blacked out, then
fell against the cell wall. Healthcare staff attended and reported a minor bruise to
the left side of Mr Honnor’s head. Mr Honnor told them he had no nausea or chest
pain. Staff took a full set of clinical observations and by the time this was completed,
Mr Honnor was back to normal. There was no further clinical intervention, the fall
was not discussed with a doctor and there was no evidence in the records that any
consideration was given to sending Mr Honnor for a CT scan (imaging test that
helps healthcare providers detect diseases and injuries).
32. On 25 June, a nurse recorded that Mr Honnor said that he was well and that there
were no issues or concerns identified. There is no record that he saw the GP.
Events of 27 June 2024
33. At around 4.18am on 27 June, an Operational Support Grade (OSG) responded to
Mr Honnor’s cell bell. He spoke to Mr Honnor’s cellmate through the observation
panel. The cellmate said that Mr Honnor was not snoring as he usually did when
sleeping and did not appear to be breathing. The OSG asked the cellmate to move
Mr Honnor’s blanket to check for breathing. He did this and said Mr Honnor was not
breathing.
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34. The OSG radioed the control room for assistance and waited outside the cell for
other prison staff to arrive. He did not radio a medical emergency code blue but told
us that he said that a prisoner was not breathing.
35. At 4.19am, Officer A arrived, followed by Officer B and a third officer. They unlocked
the cell and found Mr Honnor unresponsive with no pulse. Officer A radioed a
medical emergency code blue and began chest compressions. Around a minute
later more staff arrived. Three officers continued chest compressions on rotation.
36. A nurse attached defibrillator pads to Mr Honnor. The defibrillator advised no shock,
so chest compressions continued. The nurse told us that he and a colleague initially
struggled to locate Ambu-bag equipment to clear Mr Honnor’s airway. They were
able to locate it, but it was not connected to the oxygen supply until ambulance staff
arrived.
37. At 4.31am, paramedics arrived and took over the resuscitation. They identified flaws
in the resuscitation (as noted below) and provided guidance to prison and
healthcare staff.
38. At 5.19am, paramedics pronounced Mr Honnor dead.
39. Following Mr Honnor’s death, the paramedics who attended the emergency
response identified concerns with the quality of resuscitation administered by
healthcare and prison staff. Their specific concerns were:
• Chest compressions were performed at inadequate depth and at excessive
speed.
• Defibrillator pads were attached in incorrect locations (despite pictures on the
pads depicting the correct locations).
• Nasopharyngeal airway (NPA, a tube that is inserted into the patient’s nostril
to relieve airway obstruction) and i-gel (inserted in the mouth to provide an
open airway during resuscitation) were applied, but Mr Honnor was not being
treated with oxygen.
Post-mortem report
40. A post-mortem examination identified the cause of death as myocarditis
(inflammation of the heart muscle making it harder for the heart to pump blood).
41. The pathologist noted that myocarditis can present in a range of symptoms,
including dizziness or loss of consciousness.
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Findings
Clinical findings
Falls and head injuries
42. At Wandsworth, Mr Honnor had three documented falls as well as other episodes of
dizziness. The most recent fall was a few days before he died and the clinical
reviewer noted that two of his falls included a description of a head injury. The
nursing team assessed each of these falls and on one occasion there was an
expectation of a GP review, although the clinical reviewer noted that no GP review
of the head injuries took place.
43. The clinical reviewer found that NICE guidance suggests that a CT scan should be
undertaken when patients prescribed anticoagulants experience a head injury, no
matter how slight it is. The clinical reviewer noted that while this is guidance only,
healthcare staff should have recorded a clear record of the assessment and the
reasons for not sending Mr Honnor for a CT scan.
Hyponatremia
44. Hyponatraemia is a condition where the amount of sodium in the blood is too low.
There are many possible causes, including heart disease.
45. In May, blood tests identified low sodium levels in Mr Honnor’s blood. Although Mr
Honnor had experienced other symptoms, including dizziness, falls and low blood
pressure, the clinical reviewer noted that there were no clear pointers in his
symptoms or presentation to determine the possible reasons for the hyponatremia
and that this was an acute change since Mr Honnor arrived at Wandsworth.
46. Healthcare staff initially considered that the causes were overmedication and made
changes to Mr Honnor’s medication. The clinical reviewer found that the
investigation and assessment of the hyponatremia stopped there. She noted that
there was no assessment for other possible causes and the possible progression of
Mr Honnor’s heart failure was not considered at all.
47. The clinical reviewer found that a more structured approach to investigating Mr
Honnor’s hyponatremia should have taken place, including a case review among
the clinicians in the prison and consideration of obtaining advice from Mr Honnor’s
cardiologist or heart failure team.
CPR intervention on 27 June 2024
48. The clinical reviewer noted that the resuscitation attempt was poorly recorded and it
is not even clear who was actually present. She found that the paramedics’
concerns were well founded.
49. Healthcare staff at Wandsworth are trained to immediate life support (ILS) standard,
with refresher training every two years. Officers are trained to emergency first aid at
work standard, which includes cardiopulmonary resuscitation.
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50. A nurse told us that he recognised that healthcare staff present did not offer
effective leadership during the resuscitation and that the approach was not
compliant with current clinical guidelines. He said that he has since received
additional training.
51. We have raised our specific concerns with prison managers to ensure that action
can be taken to ensure more effective practice in real time. The Head of Healthcare
told us that she has initiated an internal investigation. The then Head of Residence
said that they were delivering more intensive first aid courses to custodial managers
and continuing to deliver emergency first aid at work training to other staff.
52. The clinical reviewer found that Mr Honnor’s heart had stopped at the beginning of
the resuscitation attempt and given the post mortem findings, a successful
resuscitation attempt was very unlikely. However, she noted that resuscitation
should always be carried out according to the Resuscitation Council guidelines.
Conclusion
53. The clinical reviewer concluded that the clinical care that Mr Honnor received at
Wandsworth was not equivalent to that he could expect to receive in the community.
As well as the issues highlighted above, the clinical reviewer also found that the
provision of care for Mr Honnor’s ring finger fracture (which he came into prison
with) and low haemoglobin level fell below expected standards and made additional
recommendations that the Head of Healthcare should consider.
54. We make the following recommendations:
• The Head of Healthcare should ensure that staff understand and follow
NICE guidelines for the management of head injuries and develop a
protocol so that prisoners prescribed anticoagulants have a formal
medical assessment after a head injury including recording a clear
decision around the need for CT scanning.
• The Head of Healthcare, alongside doctors involved in Mr Honnor’s
care, should undertake a formal significant event analysis to identify
weaknesses in the care provided and learning from these, and share
these with all clinicians working in the prison.
• The Governor and Head of Healthcare should investigate the concerns
raised by London Ambulance Service paramedics, identify any learning
and develop an action plan for improvement for individual staff as
required.
Emergency response by prison staff
55. Prison Service Instruction (PSI) 03/2013 on medical emergency response codes
sets out the actions that staff should take in a medical emergency. It contains
mandatory instructions for Governors to have a protocol to provide guidance on
efficiently communicating the nature of a medical emergency, ensuring staff take
the relevant equipment to the incident and that there are no delays in calling an
ambulance. It stipulates that if an emergency code is called over the radio, an
ambulance must be called immediately. Wandsworth uses the emergency codes
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‘red’ and ‘blue’ to comply with PSI 03/2013. Examples of the circumstances in which
staff should use code blue are when a prisoner has difficulty breathing or is
unconscious.
56. When Mr Honnor died, PSI 24/2011 covered management and security at nights. It
said that staff have a duty of care to prisoners, to themselves, and to other staff.
The preservation of life must take precedence over usual arrangements for opening
cells and where there is, or appears to be, immediate danger to life, cells may be
unlocked without the authority of the night orderly officer manager and an individual
member of staff can enter the cell on their own. (It says that they should use keys
that they carry in a sealed pouch.) Staff are not expected to take action that they
feel would put themselves or others in unnecessary danger. What they observe and
any knowledge of the prisoner should be used to make a rapid dynamic risk
assessment.
57. The policy framework Management of Internal Security Procedures has since
replaced PSI 24/2011. It contains the same information about entering cells at night
in life-threatening situations.
58. The OSG told us that he did not radio a medical emergency code blue when Mr
Honnor’s cellmate told him that Mr Honnor was not breathing. In these
circumstances, staff should use the appropriate medical emergency code in line
with national guidelines. As well as ensuring that control room staff telephone for an
ambulance immediately, it alerts healthcare staff to the nature of an emergency and
informs them about the equipment to bring. Instead, there was a delay before other
officers arrived, opened the cell and requested an ambulance.
59. The OSG told us that he did not enter Mr Honnor’s cell when he identified that he
was not breathing because he did not have a key for the cell. He said that at night,
staff did not have key access to cells. They had their own keys to the main landing
but not for individual cells. He said he needed to wait at the cell door for prison staff
to arrive after calling for assistance.
60. We asked Head of Security about the local emergency response policy for prison
staff entering cells at night. They said that staff on wing patrol duties should be in
possession of a cell key at night, in a sealed pouch to break in emergencies. The
Head of Security told us that staff should perform a three-point check before
opening a cell door alone, which includes a rapid risk assessment. They should
inform the control room before entering the cell, stating the location of the cell and
describing the circumstances that required intervention.
61. The OSG did not have a key to enter a cell at night in an emergency. This is a basic
piece of equipment that should always be carried by night patrol staff and they
cannot competently respond to a medical or other emergency without one. We have
not identified a wider issue with night staff not carrying sealed cell keys at
Wandsworth. It is also possible that the OSG was issued with a key but did not
understand what it was for or when and how to use it. We make the following
recommendation:
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• The Governor should conduct a local investigation into the events of 27
June 2024, identify and share any learning with staff and the
Ombudsman, and ensure that night patrol officers understand the
equipment they are required to carry, when and how to use it, and how
to properly communicate a medical emergency.
Inquest
62. The inquest into Mr Honnor’s death concluded on the 12 September 2025. The
coroner confirmed that Mr Honnor died of natural causes.
Adrian Usher October 2025
Prisons and Probation Ombudsman
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