Peter Lunt

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Independent investigation into
the death of Mr Peter Lunt,
on 23 February 2025 following
his release from HMP Altcourse
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, 2026
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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. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
4. Mr Peter Lunt died from cardiorespiratory failure on 23 February 2025, following his
release from HMP Altcourse on 20 February 2025. He was 55 years old. We offer
our condolences to those who knew him.
5. Mr Lunt did not have any diagnosed cardiac issues documented in his medical
records. He had a history of drug and alcohol issues, and he was supported by the
substance misuse team in prison. We did not identify any significant learning
relating to the pre-release planning or post-release supervision of Mr Lunt.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Lunt’s death on 25 February 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Lunt’s prison and
probation records.
9. We informed HM Coroner for Cheshire of the investigation. She gave us the results
of the post-mortem examination. The Coroner informed us that they were not
holding an inquest. We have sent the Coroner a copy of this report.
10. The Ombudsman’s office contacted Mr Lunt’s next of kin to explain the investigation
and to ask they had any matters they wanted us to consider. They did not respond.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Altcourse
12. HMP Altcourse is a category B prison which holds male prisoners who have either
been convicted or are on remand. It is managed by G4S. G4S provides primary
physical, mental health and substance misuse services. Castle Rock Group (CRG)
provides secondary mental healthcare.
Probation Service
13. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
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Key Events
14. On 20 January 2025, Mr Peter Lunt was charged with threatening behaviour and
sentenced to 12 weeks in prison. He was sent to HMP Altcourse. Mr Lunt was due
to be released one month later on 20 February.
15. Prior to entering prison, Mr Lunt was diagnosed with epilepsy (a condition that
affects your brain and causes seizures) and was prescribed clonazepam. His
community GP had commenced treatment for heartburn following investigations of
chest pain in 2021.
16. Mr Lunt had a history of drug and alcohol use. While in the community, Mr Lunt had
been assessed for an Acquired Brain Injury. However, it could not be officially
diagnosed until he had stopped using drugs and alcohol for three months. Mr Lunt
did not have a period of abstinence so he was unable to get a formal diagnosis.
17. During his initial healthcare reception screen at Altcourse, Mr Lunt said that he had
epilepsy, asthma, depression and a heart condition, however he did not specify
what heart condition he had. There is no record of Mr Lunt being diagnosed with a
heart condition in his medical notes, communication letters or on his GP summary
sheet. Mr Lunt was prescribed clonazepam and pregabalin in prison to manage his
seizures and mirtazapine to manage his depression.
18. On 22 January, a nurse completed Mr Lunt’s secondary reception screen, and
noted he reported that he had suspected heart disease, but the nurse found no
supporting information to confirm any cardiac issues in his medical record. During
his most recent time in prison, there were no recorded seizures in Mr Lunt’s medical
record. His last reported seizure was on 30 September 2024. However, this was an
unwitnessed seizure and therefore limited information was recorded about the
incident.
19. Mr Lunt was prescribed 50ml methadone (opioid substitution medication) and was
placed on a diazepam detoxification programme for alcohol withdrawal. He was
located on Furlong wing, the drug and alcohol wing, where he received support
from the substance misuse team.
20. On 30 January, a member of the substance misuse team and a nurse , completed
an initial assessment with Mr Lunt. They discussed harm minimisation and
tolerance levels and trained him on the use of naloxone (medication that reverses
the effects of an opioid overdose).
21. Mr Lunt had regular keyworker sessions at Altcourse. He consistently told officers
that he had no issues with his physical health and that he felt okay.
22. On 3 February, a member of the substance misuse team saw Mr Lunt. He said that
he was being released later that month. She told Mr Lunt that she would provide
him with an appointment for CGL Halton (Change, Grow, Live - community drug
and alcohol team). Mr Lunt asked that CGL pick him up from prison on the day of
his release.
23. On 19 February, two workers from CGL completed Mr Lunt’s assessment in
preparation for his release for the following day. They confirmed with Mr Lunt that
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CGL staff were going to collect him from the prison and take him to his induction
appointment with the Probation Service and CGL. They noted that Mr Lunt was
eager to engage with CGL.
24. On 20 February, Mr Lunt was released from Altcourse. CGL met him at the gate
and accompanied him to his appointments. He was released with a naloxone kit
and seven days’ supply of his prescribed medication.
25. During his probation appointment, his Community Offender Manager (COM), noted
that Mr Lunt appeared tired and was constantly being prompted to stay awake. She
asked him why he was so tired and he said he was given his medication in the early
hours of the morning, then he was woken up early to be released, and that he was
still feeling the effects of the medication.
26. Mr Lunt then attended his initial appointment with CGL Halton. The Safeguarding
Lead at CGL contacted his COM after the appointment because they were
concerned about Mr Lunt’s presentation as he again appeared tired and he was
struggling to stay awake. CGL informed his COM that they were going to arrange a
post-prison release meeting with partner agencies the following week to ensure Mr
Lunt would receive all the support he needed in the community. Unfortunately, Mr
Lunt died before this meeting took place.
Circumstances of Mr Lunt’s death
27. On 22 February, Mr Lunt stayed at his friend’s house. At approximately 7.46pm his
friend called 999, when she realised he had been lying in the same position on the
bed for several hours. She told the paramedics that Mr Lunt had become
incontinent at some point, and she tried to wake him up, but he was unresponsive
and rigid. She said that Mr Lunt had not taken any drugs, but that he had consumed
alcohol earlier that day. She did not recall Mr Lunt complaining of feeling unwell
prior to his death.
28. At 7.53pm, the paramedics arrived and at 7.58pm, they pronounced life extinct.
Post-mortem report
29. The post-mortem report gave Mr Lunt’s cause of death as cardiorespiratory failure,
caused by ischaemic heart disease due to coronary artery atheroma, left ventricular
hypertrophy, and acute bronchitis. Epilepsy contributed to but did not cause Mr
Lunt’s death.
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Findings
Healthcare
30. During his healthcare screens on arrival at Altcourse, Mr Lunt said that he had a
heart condition. The healthcare team could not find any evidence in his medical
record of him having a history of cardiac issues and he did not report any heart
problems while in prison.
31. We make no recommendations.
Director and Head of Healthcare to note
32. According to the ‘Follow up to Deaths in Custody Policy Framework’, staff must
comply with requests for information from the PPO. The investigator asked the
healthcare team at Altcourse if they had sought clarification from Mr Lunt’s
community GP about any history of heart problems. They did not respond.
33. The regional safety lead emailed all relevant parties and asked them for a response
to the PPO’s query, but the healthcare provider still failed to respond. We find the
lack of response both concerning and disrespectful and we bring the matter to the
attention of the Director and the Head of Healthcare.
Adrian Usher
Prisons and Probation Ombudsman November 2025
6 Prisons and Probation Ombudsman
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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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