Peter Howard

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Peter Howard,
a prisoner at HMP Littlehey,
on 15 June 2018
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, 2025
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
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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Peter Howard died on 15 June 2018 of malignant melanoma, a type of cancer, while a
prisoner at HMP Littlehey. He was 67 years old. I offer my condolences to Mr Howard’s
family and friends.
Although Mr Howard received a good standard of nursing care and support at Littlehey, I
am concerned that some aspects of his care were not equivalent to the standard of care
he could have expected to receive in the community.
There was a delay in prison healthcare staff chasing up Mr Howard’s hospital appointment
for a cancer review. The prison then cancelled the appointment because there were not
enough prison staff to escort Mr Howard. Lack of escorting staff also led to a month’s
delay in Mr Howard attending hospital for a biopsy, which subsequently showed his cancer
had returned. These delays were unacceptable. We cannot say whether they affected the
outcome for Mr Howard, but they may have done.
The prison needs to ensure that it facilitates prisoners’ attendance at hospital
appointments. This is not the first time we have raised this issue with Littlehey. Given the
number of older prisoners at Littlehey, the issue is not going to go away and needs to be
resolved.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman July 2019
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Findings ........................................................................................................................... 6
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 7 March 2012, Mr Peter Howard was sentenced to 13 years imprisonment for
sexual offences. He was moved to HMP Littlehey on 8 August 2014.
2. In March 2016, Mr Howard was successfully treated for malignant melanoma (a
type of cancer, typically found in the skin) on his back. In November, his consultant
told him he would be reviewed in three months. In April 2017, a prison GP noted
that Mr Howard had not received a hospital appointment and chased it up. Mr
Howard was given an appointment for 11 May 2017, but the prison cancelled it
because it had no staff available to escort him to hospital. The appointment was
rebooked for 18 May but was again cancelled by the prison. A new appointment
was given for July but was cancelled by the hospital.
3. Mr Howard was eventually seen on 7 August, when his consultant noted a lump
next to his scar and requested a biopsy and a CT scan. Mr Howard did not have
the biopsy until 7 September, because the earlier dates offered by the hospital were
at times the prison could not accommodate.
4. On 14 September, Mr Howard was admitted to hospital with a fever. While in
hospital, he was told the biopsy showed his melanoma had returned. Two weeks
later, Mr Howard was told the cancer had spread to his lungs and was unlikely to be
curable.
5. The cancer continued to spread and on 12 June, Mr Howard was given weeks to
live. He was moved to St John’s Hospice on 14 June, where he died at 8.45am the
next day.
Findings
6. A prison GP appropriately referred Mr Howard under the ‘two week pathway’ for
suspected cancer to enable his cancer to be diagnosed and treated.
7. Prison healthcare staff should have chased up Mr Howard’s cancer review
appointment with the hospital earlier.
8. It was unacceptable that, when Mr Howard was given appointments in May 2017,
the prison cancelled them because of lack of escorting staff.
9. There was also a delay in Mr Howard attending hospital for his biopsy because the
original times offered were outside the ideal times at which the prison could provide
escorts. This meant that the prison rejected several earlier appointments offered to
Mr Howard and that he waited one month for his biopsy.
10. These aspects of Mr Howard’s care were not equivalent to that which he could have
expected to receive in the community.
11. We cannot say whether these delays affected the outcome for Mr Howard, although
they may have done.
12. It is not acceptable for a prisoner with suspected or diagnosed cancer to have a
hospital appointment cancelled or postponed because staff are not available to
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
escort him. Prison staff should make decisions about medical appointments on the
basis of healthcare advice about clinical need.
Recommendations
• The Head of Healthcare should ensure that healthcare staff chase up cancer follow
up appointments promptly if they have not been received when due.
• The Governor and Head of Healthcare should ensure that:
• healthcare and prison staff communicate to ensure that prison staff understand
which appointments are clinically urgent or essential; and
• appropriate arrangements are in place to enable prisoners to attend hospital
appointments when required.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Littlehey informing
them of the investigation and asking anyone with relevant information to contact
her. Four prisoners wrote to the investigator as a result.
14. The investigator obtained copies of relevant extracts from Mr Peter Howard’s prison
and medical records.
15. NHS England commissioned a clinical reviewer to review Mr Howard’s clinical care
at the prison.
16. We informed HM Coroner for Cambridgeshire and Peterborough of the
investigation. The coroner gave us the results of the post-mortem examination. We
have sent the coroner a copy of this report.
17. The investigator wrote to Mr Howard’s wife to explain the investigation and to ask if
she had any matters she wanted the investigation to consider. Mrs Howard asked
why some of her husband’s three-monthly hospital check-ups were missed; said
she was concerned that her husband might have missed out on spending time with
his family due to delays in receiving treatment to prolong his life; and asked why her
husband had not been transferred to a hospice sooner.
18. The investigation has assessed the main issues involved in Mr Howard’s care,
including his diagnosis and treatment, whether appropriate palliative care was
provided, his location, security arrangements for hospital escorts, liaison with his
family, and whether compassionate release was considered.
19. We shared our initial report with HM Prison and Probation Service (HMPPS). The
prison disputed that they had cancelled Mr Howard’s hospital appointments in May
2017. However, we are satisfied that hospital records show that the prison
cancelled the appointments. HMPPS provided an action plan which is annexed to
this report.
20. We provided a copy of our initial report to the solicitors representing Mr Howard’s
wife. They did not identify any factual inaccuracies.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Littlehey
21. HMP Littlehey in Cambridgeshire is a medium security prison housing
approximately 1,200 men. A high proportion of the prison’s population are men who
have been convicted of sexual offences.
22. Northamptonshire Healthcare NHS Foundation Trust provides healthcare services
at Littlehey. The prison healthcare centre is open from 7.30am to 7.30pm Monday
to Friday, and from 8.00am to 5.30pm at weekends. A local practice provides GP
services, and there is a range of nurse-led clinics. There are no inpatient beds at
the prison.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Littlehey was conducted in March 2015.
Inspectors reported that a small group of GPs who regularly attended the prison
had significantly improved patient care. Lifelong conditions were identified
effectively and there was an appropriate range of clinics, led by specialist nurses.
24. An exceptional end-of-life suite had been installed since the last inspection. A
nurse with extensive specialist experience supported prisoners with palliative and
end-of-life care. There was excellent compassionate joint working between the
health provider, prison and community services for prisoners with palliative care and
end-of-life needs.
Independent Monitoring Board
25. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 January 2018, the Board
noted that access to and satisfaction with healthcare services appeared to be
broadly comparable with that in the community (with the exception of podiatry).
26. They reported that 46% of the prison’s population were aged 50 or over and that
this elderly population placed significant demands on the prison’s healthcare
services. They also noted that there were around 30 booked hospital appointments
each week (excluding emergency admissions), as well as labour-intensive
bedwatches, and they were concerned that “financial imperatives may undermine
clinical need”.
27. The Board was disappointed to note once again that the end-of-life suite, completed
in 2013, continued to be unused, reportedly due to a lack of funding. However, they
noted that the prison’s working relationship with the local hospice was positive,
enabling men to opt for end of life care where they could be surrounded by family
and friends.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Previous deaths at HMP Littlehey
28. Mr Howard was the 26th death at Littlehey since June 2015. All were from natural
causes. Since Mr Howard’s death there have been three further deaths from
natural causes. We have previously made a recommendation to the Governor
about appropriate arrangements being put in place so that prisoners are able to
attend hospital appointments.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
The diagnosis of Mr Howard’s terminal illness and informing him of his
condition
29. On 7 March 2012, Mr Peter Howard was sentenced to 13 years imprisonment for
sexual offences and sent to HMP Norwich. On 8 August 2014, he was moved to
HMP Littlehey.
30. On 8 December 2015, Mr Howard complained about a mole on his back that had
been bleeding. A prison GP examined the mole and made an urgent referral to
Addenbrookes Hospital under the NHS pathway that requires patients with
suspected cancer to be seen by a specialist within two weeks.
31. In January 2016, Mr Howard was diagnosed with malignant melanoma (a type of
cancer that develops from pigment-containing cells called melanocytes, typically in
the skin). On 19 March, the mole and some surrounding tissue were removed. On
10 June, Mr Howard’s consultant told him that the removal of his cancerous mole
appeared to have been successful. His consultant reviewed him again on 11
November and told him he would be reviewed again in three months’ time with
follow-ups every three to four months for the next three years.
32. Mr Howard should have been reviewed in February 2017 but his consultant did not
request a review on the hospital’s computer system and an appointment was never
sent. On 20 April 2017, a prison GP contacted Addenbrookes Hospital to chase
this up. Hospital records show that on 24 April, Mr Howard was given an
appointment for 11 May, which the prison cancelled on 4 May (the hospital records
do not show who at the prison cancelled the appointment). The hospital rebooked
the appointment for 18 May, which according to hospital records, the prison
cancelled again (the hospital records do not show who at the prison cancelled the
appointment). There is a note on Mr Howard’s prison healthcare record saying that
the prison cancelled an appointment in May because there were not enough staff
available to escort Mr Howard to hospital. However, the prison has told us that this
entry was incorrect and it does not accept that it cancelled either of the
appointments in May.
33. Mr Howard was given a new appointment for 11 July, which was cancelled by the
hospital. He was given another appointment for 7 August.
34. A prison GP reviewed Mr Howard on 6 June. She noted a fibrous lump around the
scar on his back (caused by a previous infection during the healing process), but
this had remained unchanged since his previous mole removal surgery. She
checked his back, chest and neck but could not see anything suspicious to suggest
his cancer had returned. On 12 June, another prison GP agreed with these
findings.
35. On 31 July, a prison GP prescribed Mr Howard with antibiotics when a cyst
developed on the upper end of the surgery scar on his back. The cyst was swollen,
red and hot to the touch. Mr Howard did not complain of any other symptoms.
36. On 7 August, Mr Howard saw a consultant dermatologist at Addenbrookes Hospital.
The consultant requested a biopsy of the scar tissue and a CT scan.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
37. Mr Howard’s biopsy was booked for 7 September. A prison healthcare
administrator had tried to arrange an earlier appointment but the dates offered by
the hospital were outside the hours the prison could accommodate. (The prison
could only accommodate between 09.00am and 10.30am and between 2.00pm and
3.30pm.)
38. On 14 September, Mr Howard developed a fever and collapsed. He was taken to
Hinchingbrooke Hospital. The lesion on his back was found to be infected and he
was given strong antibiotics. While Mr Howard was in hospital, the biopsy results
showed his melanoma had returned.
39. Prison healthcare staff should have noticed sooner that Mr Howard had not
received an appointment for his cancer review, due in February 2017, and chased
this up earlier.
40. There was then a further delay after the prison cancelled his May appointments due
to a lack of staff available to escort him to hospital. (The prison disputes that it
cancelled the appointments on 11 and 18 May but we are satisfied that the hospital
records show otherwise.)
41. There was also a delay in Mr Howard having his biopsy because the appointment
times offered by the hospital were outside the ideal times at which the prison could
provide escorts.
42. Both these aspects of Mr Howard’s care were not equivalent to that which he could
have expected to receive in the community.
43. We cannot say whether these delays affected the outcome for Mr Howard, although
they may have done. It is not acceptable for a prisoner with suspected or
diagnosed cancer to have a hospital appointment cancelled or postponed because
staff are not available to escort him. Prison staff should make decisions about
medical appointments on the basis of healthcare advice. We make the following
recommendations:
The Head of Healthcare should ensure that staff chase up cancer follow up
appointments promptly if they have not been received when due.
The Governor and Head of Healthcare should ensure that:
• healthcare and prison staff communicate to ensure that prison staff
understand which appointments are clinically urgent or essential; and
• appropriate arrangements are in place to enable prisoners to attend
hospital appointments when required.
Mr Howard’s clinical care
44. On 27 September, Mr Howard saw his consultant at Addenbrookes Hospital who
told him that the CT scan had showed cancerous nodules in his lungs and a mass
on his chest wall. He said the cancer was unlikely to be curable. He offered
medication to help try and shrink his cancer but said this treatment would be to
extend his life only. Mr Howard started on dabrafenib and trametinib (cancer
medication) the same day.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
45. Mr Howard saw a specialist registrar at Addenbrookes Hospital for review on 25
October and 22 November. He was tolerating treatment well and a CT scan on 20
December, showed that the tumour on his chest wall had reduced in size and the
nodules on his lungs had improved, with some disappearing altogether. He was
asked to continue with his treatment.
46. Mr Howard was admitted to Addenbrookes Hospital on 19 March 2018 when the
lesion on his back became infected. He had surgery to remove infected tissue and
a skin graft to help close the wound. A CT and MRI scan on 23 March showed that
his cancer had now spread to his kidneys. A nodule was also found on his brain.
Mr Howard was discharged back to prison on 27 March.
47. On 4 April, Mr Howard saw an oncologist to discuss his scan results. Mr Howard
agreed to try pembrolizumab, a drug given intravenously every three weeks as an
outpatient in the oncology day unit. It was explained as his cancer had now
advanced this would be the only treatment available to him.
48. The following day, on 5 April, a consultant in palliative medicine and the prison’s
palliative care nurse met Mr Howard and his wife during a prison visit to discuss his
cancer and answer any questions they had. After discussion Mr Howard said he
did not want anyone to resuscitate him if his heart or breathing stopped and signed
a DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) order to that effect.
49. Mr Howard attended Addenbrookes oncology day unit on 18 April to start his
treatment. The oncologist said he would be reviewed weekly, with a CT scan in
three months. Treatment would be stopped early if his condition deteriorated.
50. Mr Howard was admitted to Addenbrookes Hospital on 21 May with a fever, chest
pain and a productive cough. A scan showed patchy consolidative areas (tissue
that has filled with liquid instead of air) in his lungs, with signs of recent bleeding in
his left kidney and behind one of his lungs. Mr Howard had a blood transfusion,
antibiotics and steroids for a suspected chest infection. He was discharged back to
the prison on 7 June.
51. The prison’s palliative care nurse visited Mr Howard in his cell on 11 June to
discuss his end of life wishes. Mr Howard said if he could not go home he would
like to go to a hospice. He complained of pain overnight and the nurse arranged for
fentanyl 12-hour pain release patches to be provided. She also spoke to the
pharmacy about leaving a small amount of oramorph in his cell overnight for
breakthrough pain.
52. On 12 June, a prison GP asked the consultant in palliative medicine to visit the
prison for an urgent palliative care review. Mr Howard’s pain had increased, he
was unsteady on his feet and was now sleeping much of the day. The consultant
said that Mr Howard’s prognosis was likely to be weeks. She discussed hospice
admission for pain control but Mr Howard was not keen and became tearful. He
was aware how sick he was but felt it was not time for a hospice yet. The
consultant reassured him that his admission would be for pain control only and once
this improved he would be transferred back to the prison. On this basis Mr Howard
agreed. The consultant sent a non-urgent referral to St John’s Hospice in Bedford.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
53. Mr Howard was moved to St John’s Hospice on 14 June when a bed became
available. He died at 8.45am the next day. An officer was with Mr Howard when he
died.
54. The clinical reviewer was satisfied that the primary medical, nursing and supportive
care Mr Howard received at Littlehey was of a good standard and was at least
equivalent to that which he could have expected to receive in the community.
Mr Howard’s location
55. After Mr Howard’s cancer diagnosis, he was reviewed by the prison’s disability
liaison officer and a care plan was put in place. Mr Howard received help to collect
his meals and clean his cell, and when his mobility reduced he used a wheelchair to
attend the visits hall and healthcare appointments. He was also issued with a
personal alarm in case of a fall.
56. On 8 and 11 June 2018, the palliative care nurse spoke to Mr Howard and offered a
move to a larger cell in the prison’s ‘dignity suite’ where enhanced nursing care
could be provided. Mr Howard declined the move, asking to remain with his friends
on the wing.
57. The hospital discharge paperwork on 7 June shows that no follow-up was required
and he was fit for discharge back to prison. The consultant in palliative medicine
made the referral to the hospice on 12 June on the basis that he would return to the
prison once his symptoms were under control and not for end of life care. There is
no evidence that Mr Howard should have gone to the hospice earlier than he did.
Restraints, security and escorts
58. When prisoners have to travel outside the prison, a risk assessment determines the
nature and level of security arrangements, including restraints. The Prison Service
has a duty to protect the public but this has to be balanced with a responsibility to
treat prisoners with humanity. Any restraints used should be necessary and
decisions should be based on the security risk taking into account factors such as
the prisoner’s health and mobility.
59. In December 2017, a CT scan showed that Mr Howard was responding to treatment
well. He was fully mobile at the time. On 14 February 2018, Mr Howard was taken
to Addenbrookes Hospital for an oncology review. A prison risk assessment
showed that he was at low risk of escape and a medium risk to the public. He was
fully mobile and escorted by two prison officers. An escort chain was used. (An
escort chain is a long chain with a handcuff at each end, one of which is attached to
the prisoner and the other to an officer.) We are satisfied that the level of restraint
used was appropriate.
60. When Mr Howard was taken to hospital on 19 March, he was escorted by two
officers and no restraints were used. Restraints were not used again.
Liaison with Mr Howard’s family
61. The prison’s family liaison officer (FLO) visited Mr Howard in his cell on 27 March
2018 to introduce himself. He explained his role and asked for permission to
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
contact his wife, who he spoke to later that day. The FLO kept in regular contact
with Mr Howard.
62. After Mr Howard was admitted to hospital, the FLO contacted Mr Howard’s wife on
27 May when his condition worsened. He met Mrs Howard and Mr Howard’s sister
at the hospital the next day.
63. Mr Howard was moved to St John’s Hospice on 14 June. The FLO spoke to Mrs
Howard the same day to tell her that Mr Howard was now at the hospice and she
could visit in line with the hospice rules. Mr Howard died the next morning. Mrs
Howard was due to travel to the hospice from Norwich that morning. To avoid
missing her, the FLO telephoned Mrs Howard to tell her that her husband had died.
He travelled to Norwich the same day to visit Mrs Howard and provide support.
64. Mr Howard’s funeral was on 25 July 2018. The prison contributed to funeral costs in
line with national policy.
Compassionate release
65. Prisoners can be released from custody before their sentence has expired on
compassionate grounds for medical reasons. This is usually when they are
suffering from a terminal illness and have a life expectancy of less than three
months.
66. Mr Howard started his pembrolizumab treatment on 18 April 2018. Mr Howard’s
consultant sent a letter to the prison on 23 April 2018. She said that while Mr
Howard was in the early stages of his treatment, his prognosis was unclear and she
was therefore unable to write a letter in support of an application for compassionate
release.
67. On 12 June, a prison GP asked the consultant to visit the prison for an urgent
palliative care review. She gave a prognosis of weeks and agreed to write a letter
in support of compassionate release. Mr Howard died before an application for
compassionate release could be completed. We consider that compassionate
release was considered appropriately.
Inquest
68. The inquest, held on 27 May 2025, concluded that Mr Howard died from natural
causes.
69. The healthcare provider at Littlehey submitted evidence about the hospital
appointments on 11 and 18 May 2017. The healthcare provider accepted that they
had cancelled the appointments. They thought the most likely scenario was that
when they received those hospital appointments, the list of hospital escorts was
already full and so they cancelled the appointments and asked the hospital to
rearrange. There is no evidence that prison staff were approached to ask for
hospital escorts for Mr Howard on those occasions.
10 Prisons and Probation Ombudsman
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