Staff at Wandsworth Prison failed to perform proper CPR on a dying prisoner and delayed emergency response after his cellmate raised the alarm, according to a damning watchdog investigation [pdf].
Peter Honnor died of heart inflammation on 27 June 2024, less than two months after arriving at the category B prison. A Prisons and Probation Ombudsman report released this week documents multiple failures: healthcare staff who didn’t follow medical guidelines for head injuries, a night patrol officer who lacked a mandatory cell key, and resuscitation efforts so inadequate that paramedics raised formal concerns.
The clinical reviewer concluded that the care Mr Honnor received at Wandsworth “was not equivalent to that he could have expected to receive in the community.”
Mr Honnor becomes the 20th person to die at Wandsworth since June 2021.
Three falls, no CT scan, deteriorating health
Mr Honnor arrived at Wandsworth on 6 May 2024, remanded for threatening a person with a blade. It was his first time in prison. He had a complex history of heart attacks and heart failure.
Over seven weeks, he experienced at least three falls with head injuries, including one on 22 June – five days before he died – where he blacked out and hit his head against a cell wall. Healthcare staff assessed each fall but never arranged a CT scan, despite NICE guidance recommending scans for patients on anticoagulants who experience head injuries. Mr Honnor was prescribed edoxaban, a blood-thinning medication.
Healthcare staff also identified low blood sodium levels – a potential indicator of worsening heart failure – but stopped investigating after changing his medication. The clinical reviewer found they should have taken a more structured approach, potentially consulting Mr Honnor’s cardiologist or heart failure team.
On 25 June, a nurse recorded that Mr Honnor said he was well. Two days later, he was dead.
Night patrol officer had no cell key in emergency
At around 4.18am on 27 June, an Operational Support Grade officer responded to Mr Honnor’s cell bell. His cellmate said Mr Honnor was not breathing. The OSG radioed for help but did not call a medical emergency code blue and told investigators he could not enter the cell because he was not carrying a mandatory cell key in a sealed pouch.
Prison policy states that night patrol staff should carry cell keys for emergencies and that preservation of life takes precedence over usual procedures.
The OSG waited outside for other officers. At 4.19am – a minute after the alarm had gone off – another officer arrived and unlocked the cell. They found Mr Honnor unresponsive with no pulse and began chest compressions.
Paramedics arrived at 4.31am – 13 minutes after the initial alarm. They identified multiple problems with the ongoing resuscitation. At 5.19am, they pronounced Mr Honnor dead.
“Inadequate depth and excessive speed”
London Ambulance Service paramedics filed formal concerns about the resuscitation they witnessed:
- Chest compressions performed at inadequate depth and excessive speed
- Defibrillator pads attached in incorrect locations, despite pictures on the pads showing correct placement
- Airway devices applied, but Mr Honnor not being treated with oxygen
A nurse told investigators he recognised healthcare staff did not offer effective leadership during resuscitation and their approach did not comply with guidelines. He has since received additional training.
The clinical reviewer found that while successful resuscitation was very unlikely, CPR should always be carried out according to guidelines.
Four recommendations accepted
The Prisons and Probation Ombudsman made four recommendations, all accepted by HMP Wandsworth and Oxleas NHS Foundation Trust with February 2025 deadlines:
- Head of Healthcare must ensure staff follow NICE guidelines for head injuries and develop protocols for prisoners on anticoagulants
- Doctors must undertake formal analysis to identify care weaknesses and share learning
- Governor and Head of Healthcare must investigate paramedics’ concerns and develop action plan
- Governor must investigate events of 27 June and ensure night patrol officers understand required equipment and emergency procedures
A coroner confirmed Mr Honnor died of natural causes at an inquest on 12 September 2025.
The 20th death at Wandsworth since 2021
Mr Honnor was the 20th person to die at Wandsworth since June 2021. He is one of 22 deaths at Wandsworth Prison since June 2021, including 13 self-inflicted and two linked to drugs. Eight other deaths remain under active PPO investigation.
