Raymond Paterson

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of
Mr Raymond Paterson,
a prisoner at HMP Fosse Way,
on 1 July 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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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 4 May 2022, Mr Raymond Paterson was sentenced to three years imprisonment
for sexual offences.
4. Mr Paterson died of pleural empyema (an abscess) caused by squamous cell
carcinoma of the lung (lung cancer), on 1 July 2024, while a prisoner at HMP Fosse
Way. He was 79 years old. We offer our condolences to Mr Paterson’s family and
friends.
5. The Ombudsman’s office contacted Mr Paterson’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. We did not receive a
response.
6. The PPO investigator investigated the non-clinical issues relating to Mr Paterson’s
care.
7. We did not find any non-clinical issues of concern.
8. NHS England commissioned an independent clinical reviewer to review Mr
Paterson’s clinical care at Fosse Way.
9. The clinical reviewer concluded that the clinical care Mr Paterson received at Fosse
Way was of a good standard and equivalent to what he could have expected to
receive in the community.
10. He did, however, find that healthcare staff did not conduct a second stage health
assessment upon Mr Paterson’s arrival at Fosse Way, which would have provided
an opportunity to identify the need for a chronic obstructive pulmonary disease
(COPD) care plan – which was never created. We make the following
recommendations:
The Head of Healthcare should ensure all new arrivals and transfers to prison
should receive a second stage health assessment within 7 days of arrival.
11. 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.
Prisons and Probation Ombudsman 1
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12. At the inquest held on 25 November 2024, the Coroner concluded that Mr Paterson
died of pleural empyema caused by squamous cell carcinoma of the lung (lung
cancer).
Adrian Usher
Prisons and Probation Ombudsman January 2025
2 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
OFFICIAL - FOR PUBLIC RELEASE