Matthews, Elliot

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Elliot Matthews,
a prisoner at HMP Preston,
on 26 September 2023
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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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. On 15 November 2022, Mr Elliot Matthews was sentenced to 12 years in prison for
sexual offences. Mr Matthews died in hospital from bronchopneumonia, caused by
advanced squamous cell carcinoma (cancer) of the oesophagus (throat) on 26
September 2023, while a prisoner at HMP Preston. He was 52 years old. We offer
our condolences to Mr Matthews’ family and friends.
4. The PPO family liaison officer wrote to Mr Matthews’ next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
Matthews’ next of kin asked for information about Mr Mathews’ diagnosis and
treatment, and why he was not granted compassionate release. These issues have
been addressed in the clinical review and in this report.
5. NHS England commissioned an independent clinical reviewer to review Mr
Matthews’ clinical care at HMP Preston.
6. The clinical reviewer concluded that the clinical care Mr Matthews received at HMP
Preston was of a good standard and equivalent to what he could have expected to
receive in the community. The clinical reviewer made recommendations not related
to Mr Matthews’ death that the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Matthews’
care.
8. In September 2023, prison staff at Preston started an application for compassionate
release. The application was not completed before Mr Matthews died.
9. We did not find any non-clinical issues of concern. We make no recommendations.
10. We shared the initial report with Mr Matthew’s family. Mr Mathews’ mother made a
number of observations related to the clinical review, which the clinical reviewer has
amended.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies. HMPPS made comments about the clinical
review. The clinical reviewer amended the report in the light of the comments.
Adrian Usher
Prisons and Probation Ombudsman March 2024
Prisons and Probation Ombudsman 1
Inquest
The inquest, held on 2 May 2024, concluded that Mr Matthews died from natural causes.
2 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