Frederick Mills

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Independent investigation into
the death of Mr Frederick Mills,
a resident of Peterborough
Approved Premises,
on 7 November 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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 HMPPS in ensuring the standard of care received by
those within service remit is appropriate then our recommendations should be
focused, evidenced and viable. This is especially the case if there is evidence of
systemic process failures.
3. Mr Frederick Mills died in hospital on 7 November 2024 of aspiration pneumonia
resulting from complications of a brain tumour, while a resident of Peterborough
Approved Premises (AP). He was 67 years old. We offer our condolences to his
friends and family.
4. Around two weeks after he was released from prison to Peterborough AP, Mr Mills
was admitted to hospital and diagnosed with a brain tumour. Following his
discharge from hospital, Mr Mills spent around four weeks in the AP before his final
admission to hospital. Following his diagnosis, Mr Mills sometimes became
confused and needed assistance with some daily tasks such as taking his
medication. AP staff implemented additional welfare checks. They appropriately
referred Mr Mills for a social care assessment, although the outcome of the
assessment was outstanding when he died.
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The Investigation Process
5. We were informed of Mr Mills’ death on 12 November 2024.
6. The PPO investigator obtained copies of relevant extracts from Mr Mills’ prison and
probation records.
7. The Ombudsman’s office contacted Mr Mills’ next of kin, the CEO of a community
interest company that had worked with him, to explain the investigation and to ask if
she had any matters she wanted us to consider. (Community interest companies
are not for profit organisations which support vulnerable people in the community.)
Mr Mills’ next of kin asked some questions that are outside of the remit of our
investigation, and also about the social care he received at Peterborough AP.
8. We shared the initial report with HM Prison and Probation Service. They did not
identify any factual inaccuracies.
9. We also shared the initial report with Mr Mills’s next of kin. She identified one
factual inaccuracy that we have amended in this report.
2 Prisons and Probation Ombudsman
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Background Information
Peterborough Approved Premises (AP)
10. Approved premises (formerly known as probation or bail hostels) accommodate
those released from prison on licence and those directed to live there by the courts
as a condition of bail. Their purpose is to provide an enhanced level of residential
supervision in the community, as well as a supportive and structured environment.
Residents are responsible for their own healthcare and are expected to register with
a GP
11. HMPPS manages Peterborough AP. It has 27 single rooms and two double rooms.
Meals are provided and there is a communal area for eating and socialising. Each
resident has a key worker to oversee their progress and wellbeing and help them
adhere to their individual licence conditions and the premises’ rules. Staff are on
duty 24-hours a day.
Previous deaths at Peterborough Approved Premises
12. There have been no deaths within the past five years at Peterborough AP.
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Key Events
13. On 15 February 1989, Mr Frederick Mills was sentenced to life in prison for murder.
He was released in April 2020, before being recalled in March 2023 for breaching
his licence. Mr Mills was sent to HMP Bedford. Mr Mills was diagnosed with various
mental health conditions.
14. On 4 May 2023, Mr Mills was transferred to HMP Wayland.
15. On 18 September 2024, Mr Mills was released from Wayland to Peterborough AP.
Peterborough Approved Premises
16. On 28 September 2024, Mr Mills was ill and remained in bed all day. Staff
monitored him. This continued over the next two days.
17. On 2 October, Mr Mills complained of a pain in his head and was admitted to
Peterborough City Hospital. Following various tests, Mr Mills was diagnosed with a
brain tumour.
18. On 4 October, probation staff completed a Social Care Act referral for Mr Mills, to
better understand his support needs following his diagnosis. The referral highlighted
that Mr Mills’ symptoms included dizziness, sickness and confusion and that these
might worsen as his illness progressed.
19. On 5 October, Mr Mills returned to Peterborough AP. He had several GP and
hospital appointments over the following weeks, which a support worker from a
community interest company accompanied him to. Alongside this, AP staff often
had to support or remind Mr Mills to take his medication and other residents
sometimes helped him at meal times.
20. On 11 October, Mr Mills completed a self-referral to RECONNECT (RECONNECT
supports people leaving prison to access and engage with healthcare services in
the community).
21. On 12 October, AP staff requested an expedited adult social care referral. They
highlighted Mr Mills’ deteriorating condition, including that he was struggling with
mobility and could become extremely disoriented. They also noted that the AP was
not a suitable environment to meet his medical needs. AP staff began to make
additional welfare checks.
22. On 14 October, AP staff sent a letter to the local GP to request Mr Mills be referred
to Joint Emergency Team (JET, a healthcare service that provides urgent care for
people in their homes) for an assessment.
23. On 16 October, a social worker assessed Mr Mills. The outcome of this assessment
and other referrals were awaited when Mr Mills died.
24. On 21 October, a residential worker at Peterborough AP updated Mr Mills’ support
plan. This identified his diagnosis, that he needed support to take medication and
that AP staff were making additional checks on him.
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25. In the week of 28 October, Mr Mills made three visits into town. AP staff recorded
that he seemed quite bright, although on one day they noted that he was a little
confused.
26. On 3 November, Mr Mills was taken to Peterborough City Hospital following a fall in
his room. Due to his deteriorating condition, Mr Mills remained in hospital as an
inpatient.
Circumstances of Mr Mills’ death
27. On 7 November, Mr Mills died at Peterborough City Hospital in the early hours of
the morning.
Contact with Mr Mills’ family
28. Mr Mills did not have contact with his family and named a member of staff from a
community interest company as his next of kin. We do not know how they were told
of his death.
Post-mortem report
29. Mr Mills died in hospital whilst receiving treatment for his brain tumour and as such
the hospital provided the cause of death. There was no post-mortem examination.
The cause of death was recorded as aspiration pneumonia (when food, liquid, or
saliva is inhaled into the lungs instead of being swallowed properly, leading to
infection and inflammation), resulting from complications of a brain tumour.
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Findings
30. Mr Mills was in relatively good health until he was diagnosed with a brain tumour
around two weeks after he was released from prison to Peterborough AP.
31. Following his diagnosis, Mr Mills had additional care needs that meant that AP
accommodation might no longer be appropriate. He was still relatively mobile, but
sometimes became confused and required help with taking his medication or at
mealtimes. The AP team appropriately referred Mr Mills to social services to assess
and identify his social care needs, although the outcome of these referrals was
outstanding when he died.
Adrian Usher
Prisons and Probation Ombudsman October 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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