HMP Wandsworth staff failed to properly perform CPR on a prisoner who had gone into cardiac arrest, a watchdog has found. Peter Honnor, 55, died of myocarditis at the south London prison on June 27, 2024, after his cellmate reported him unresponsive.
A Prisons and Probation Ombudsman report found the night patrol officer did not immediately call a code blue emergency in response, which meant there was a delay before other officers arrived, opened the cell and called an ambulance. Paramedics later raised concerns about the quality of resuscitation performed by healthcare and prison staff before they arrived and took over.
A clinical reviewer ruled Mr Honnor did not receive the care at HMP Wandsworth that he could have expected to receive in the community.
Mr Honnor was remanded in custody to HMP Wandsworth on May 6, 2024, for threatening a person with a blade or sharply pointed article in a public place. He had a history of heart attacks and heart failure and was seen by healthcare staff many times during his short time in prison, as he experienced chest pain, dizzy spells and at least three falls – two of which resulted in a head injury.
Mr Honnor was admitted to the prison healthcare unit on May 23, where his blood pressure was monitored twice a day. He asked staff for an appointment on June 18 as he felt like he was going to pass out. He was added to the GP waiting list for June 25.
Prison staff called a code blue emergency for Mr Honnor on June 22, after he blacked out and fell against a cell wall. Staff assessed him, by which time he was back to normal. No further clinical intervention was made, the fall was not discussed with a doctor and there is no evidence any consideration was given to sending him for a CT scan.
A nurse recorded on June 25 that Mr Honnor was well. There is no record he saw a GP.
Mr Honnor’s cellmate told a night patrol officer he was not breathing at around 4.18am on June 27. The officer called for help but did not radio a code blue emergency, and told the watchdog he could not enter the cell as he was not carrying a mandatory cell key.
Other officers, followed by healthcare staff, arrived and began to perform CPR, but paramedics pronounced Mr Honnor dead at 5.19am.
A coroner confirmed Mr Honnor died of natural causes, after an inquest into his death concluded on September 12 this year.
The paramedics later said prison and healthcare staff performed chest compressions on Mr Honnor at inadequate depth and excessive speed, defibrillator pads were attached in the wrong places and he was not being treated with oxygen before they took over.
A nurse told the ombudsman he recognised healthcare staff did not offer effective leadership during the resuscitation and their approach did not comply with guidelines. The clinical reviewer found that, while Mr Honnor’s heart had already stopped and successful resuscitation was unlikely, CPR should always be carried out according to guidelines.
She also found healthcare staff stopped investigating Mr Honnor’s low blood sodium levels after changing his medication, without considering other possible causes and whether his heart failure was progressing. She found a more structured approach to investigating it should have been taken, including a case review.
The ombudsman told the prison’s governor and head of healthcare to investigate events on the night and concerns raised by paramedics, identify any learning and develop an action plan for improvement for staff as required.
Oxleas NHS Foundation Trust, which provides healthcare services to HMP Wandsworth, has been contacted for comment.
