Jamie Perfect

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Independent investigation into
the death of Ms Jamie Perfect,
a prisoner at HMP Peterborough,
on 14 October 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, 2026
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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.
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.
Ms Jamie Perfect died on 14 October 2024, after taking multiple medications, one of which
had been obtained illicitly, at HMP Peterborough. She was 29 years old. I offer my
condolences to Ms Perfect’s family and friends.
Ms Perfect, who had a history of substance misuse and tested positive for drugs when she
arrived at Peterborough, was appropriately monitored and supported by substance misuse
staff during her ten days there. The clinical reviewer found that her care was of a good
standard and equivalent to that which she could have expected to receive in the
community.
We make no recommendations.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman August 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
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Summary
Events
1. Ms Jamie Perfect was remanded to HMP Peterborough on 4 October 2024,
charged with assaulting an emergency worker.
2. Ms Perfect had a history of substance misuse and when she arrived at
Peterborough, she tested positive for opiates, cocaine, cannabis and
benzodiazepines (prescription medication used to treat anxiety but also widely
abused). She was placed on the drug stabilisation unit for assessment and
monitoring and was prescribed medication to help with drug withdrawal.
3. On 10 October, during a routine check of Ms Perfect’s cell, an officer found an
improvised vape which contained an unknown substance. The officer placed Ms
Perfect on a disciplinary charge. At the adjudication hearing the next day, Ms
Perfect denied the charge. The hearing was adjourned to allow her to obtain legal
advice.
4. At around 7.20am on 14 October, an officer unlocked Ms Perfect’s cell and found
Ms Perfect unresponsive on her bed. The officer radioed a medical emergency
code and staff started CPR. When ambulance paramedics arrived at 7.42am, they
assessed that Ms Perfect was dead and pronounced life extinct.
5. The post-mortem report concluded that Ms Perfect died from aspiration pneumonia
(when saliva, food or stomach contents enter the lungs leading to infection) caused
by polypharmacy (multiple drug use).
Findings
6. One of the drugs found in Ms Perfect’s system, tapentadol (an opioid), is not
prescribed at the prison and so it must have been brought into the prison illegally.
We do not know how Ms Perfect obtained it.
7. The last HMIP report found that Peterborough had taken important steps to limit
drug supply but like all women’s prisons, had no body scanner to detect secreted
items, which was a risk. It also found that the prison’s drugs strategy covered both
the men’s and women’s prison so issues more specific to female prisoners, such as
trading medications, were not addressed. In December 2024, Peterborough issued
an updated drugs strategy for the women’s prison. While it says that diversion of
medication is the most significant drug-related issue among female prisoners, it
does not say how that will be tackled. We bring this to the Director’s attention.
8. Ms Perfect was referred for SMS support when she arrived at Peterborough and
received daily SMS monitoring. The clinical reviewer concluded that Ms Perfect’s
clinical care was of a good standard and equivalent to that which she could have
expected to receive in the community.
9. We make no recommendations.
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The Investigation Process
10. HMPPS notified us of Ms Perfect’s death on 14 October 2024.
11. The investigator issued notices to staff and prisoners at HMP Peterborough
informing them of the investigation and asking anyone with relevant information to
contact her. No one responded.
12. The investigator visited Peterborough on 22 October. She obtained copies of
relevant extracts from Ms Perfect’s prison and medical records.
13. The investigator interviewed four members of staff at Peterborough on 28
November and a prisoner by telephone on 27 March 2025.
14. NHS England commissioned an independent clinical reviewer to review Ms
Perfect’s clinical care at the prison and she conducted joint interviews with the
investigator.
15. We informed HM Coroner for Cambridgeshire & Peterborough of the investigation.
The investigation was suspended from 20 January until 18 March 2025 as we
waited for the post-mortem and toxicology reports. The Coroner gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
16. The Ombudsman’s office contacted Ms Perfect’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond.
17. We shared our initial report with HMPPS and the prison’s healthcare provider,
Northamptonshire Healthcare NHS Foundation Trust. They found no factual
inaccuracies.
18. We sent a copy of our initial report to Ms Perfect’s mother. She did not notify us of
any factual inaccuracies but raised some queries which we have addressed in
separate correspondence.
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Background Information
HMP Peterborough
19. HMP Peterborough is operated by Sodexo Justice Services. It holds men and
women in separate sides of the prison. The women’s side of the prison holds almost
400 women. There is 24-hour healthcare provision. Northampton Healthcare
Foundation Trust provides healthcare services.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Peterborough (Women) was in November 2023.
The Chief Inspector noted that overall, the prison had supportive relationships
between staff and prisoners.
21. Inspectors noted that from their survey, 27% of prisoners said it was easy to obtain
illicit drugs, which was in line with other women’s prisons. Some important steps
had been taken to reduce the supply of illicit items. For example, all social mail was
now photocopied, CCTV had been upgraded and there was now a dedicated team
of dog handlers. Enhanced gate security had been introduced, which was not seen
in other women’s prisons. Like all other women’s prisons, there was no body
scanner to detect secreted items, which was a risk. The proportion of drug test
results proving positive was one of the lowest among women’s prisons at 5.95%. All
suspicion testing was completed and only a small number came back positive.
22. Inspectors noted that the prison’s drug supply action plan was the same across the
men’s and women’s prisons and did not focus on supply and demand specific to the
women’s population, such as the increased likelihood of prescribed medication
being traded.
23. Inspectors noted that the substance misuse services were well led and delivered by
a skilled team. Women needing substance misuse treatment and alcohol
detoxification were identified at reception and received appropriate care.
Independent Monitoring Board
24. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 31 March 2024, the IMB reported
that life for prisoners at Peterborough was generally calm and well-ordered, with
little violence. IMB members observed positive working relationships between staff
and prisoners. The Board noted that prisoners very seldom raised concerns about
the drug and alcohol rehabilitation service.
Previous deaths at HMP Peterborough
25. Ms Perfect was the third female prisoner to die at Peterborough in three years. Of
the previous deaths, one was drug related and one was from natural causes.
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Key Events
26. Ms Jamie Perfect was remanded in prison, charged with assaulting an emergency
worker, on 4 October 2024. She was sent to HMP Peterborough. She had been at
Peterborough several times before.
27. Ms Perfect had a history of alcohol and drug misuse, including heroin, crack
cocaine, cannabis, and illicit prescription medication. When she arrived at
Peterborough, she tested positive for opiates, tetrahydrocannabinol (THC – found in
cannabis), cocaine and benzodiazepines (prescription medication used to treat
anxiety but also widely abused).
28. On 5 October, a nurse from the substance misuse service (SMS) completed a
medication review. She noted that Ms Perfect had not collected her ADHD
medication since June 2024. She prescribed standard methadone titration (starting
at 10mls and increasing to 30mls over three days) and supportive medications to
help with the symptoms of drug withdrawal. Ms Perfect asked to start with Buvidal
injections (used to treat opiate dependence as it blocks the feel-good effects of
opiates) so she was added to the clinic waiting list to start.
29. Ms Perfect was allocated a single cell on the upper landing of B2 of the induction
integrated drug treatment service (IDTS) wing for assessment and monitoring.
30. The remote SMS team GP completed a monitoring review. She noted that
methadone stabilisation had already begun so she prescribed diazepam for the
benzodiazepine withdrawal to cover from 5 October until 14 October.
31. The SMS team assessed Ms Perfect daily. Ms Perfect told SMS staff that she
smoked £200 - £300 of cocaine a day and an unlimited amount of cannabis. She
had been taking illicit diazepam (a benzodiazepine) and buprenorphine (an opiate)
when she could.
32. During a meeting with SMS staff on 9 October, Ms Perfect told a GP she was not
managing on her methadone and asked for an increase. She told the GP that she
wanted to stabilise on methadone and then receive the Buvidal injection. The GP
increased her methadone dose to 35mls and then from 11 October, 40mls. SMS
nurses administered the methadone in accordance with the prescription.
33. On the morning of 10 October, during a routine cell check, an officer found a bag
containing an improvised vape containing an unknown substance. (Vapes are often
modified and used to smoke illicit substances.) Prison staff issued her with a notice
that she would have an adjudication (disciplinary hearing) the next day. At the
adjudication hearing on 11 October, Ms Perfect pleaded “not guilty” and the matter
was adjourned for her to obtain legal advice.
34. On 13 October, Ms Perfect was on her wing, interacting with staff and prisoners
throughout the day. (Intelligence reports submitted after Ms Perfect’s death say that
Ms Perfect had been asking other prisoners for foil from their chocolate wrappers.)
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Events of 14 October 2024
35. The investigator watched CCTV footage and body worn video camera (BWVC)
footage from 14 October. She also obtained information from the East of England
Ambulance Service. The following account has been taken from all sources.
36. At 4.09am, an operational support officer completed a roll check (a visual check into
all cells to check that all prisoners are accounted for) and reported no issues.
37. At 7.23am, Prison Custody Officer (PCO) A unlocked Ms Perfect’s cell door. In her
written statement, she said that she called “Good morning” and got no response.
She saw that Ms Perfect was lying on her bed on her right-hand side but could not
see her face as her hair was covering it. She could not see any movement so she
entered the cell. She touched Ms Perfect’s leg which was cold and stiff so she
radioed a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties that alerts healthcare staff and tells the
control room to call an ambulance immediately). She turned Ms Perfect onto her
back, which was difficult as she was so stiff, and shouted to PCO B for help. When
PCO B arrived, they moved Ms Perfect to the floor and began CPR.
38. Nurse A was the first nurse to arrive. She shouted for more nurses to attend and for
someone to bring the medical bag. She noted that Ms Perfect had rigor mortis
(stiffening of the body after death). Three nurses and a healthcare assistant joined
her. They attached a defibrillator which advised no shock. Nurse A tried to insert an
airway but was unable to as Ms Perfect’s jaw was stiff.
39. Staff moved Ms Perfect out of the cell and onto the landing for more space. For
privacy they placed screens and continued with the resuscitation attempts.
40. The ambulance log noted that the telephone call was received at 7.25am.
Paramedics arrived at the gate at 7.37am. Paramedics noted in their log that they
were delayed in getting to Ms Perfect due to prison protocols of “getting through
numerous locked gates and escorts”. Ambulance staff were with Ms Perfect at
7.42am and noted that rigor mortis was present. They stopped CPR and
pronounced life extinct at 7.43am.
Contact with Ms Perfect’s family
41. The prison appointed a supervising officer (SO) as the family liaison officer on 14
October. She and a member of the chaplaincy team visited Ms Perfect’s mother that
day. She was not at home. A few hours later, they returned to Ms Perfect’s mother’s
address after she phoned the prison having already heard her daughter had died,
and confirmed the news and offered support. (We do not know who phoned Ms
Perfect’s mother.)
42. The prison contributed to the cost of Ms Perfect’s funeral, in line with national
guidelines.
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Support for prisoners and staff
43. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
44. After Ms Perfect’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support. Listeners
visited the wing to offer support and inform prisoners of the support available.
45. The prison posted notices informing other prisoners of Ms Perfect’s death, and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Ms Perfect’s death.
Post-mortem report
46. The post-mortem report concluded that Ms Perfect’s death was due to aspiration
pneumonia (when saliva, food or stomach contents enter the lungs leading to
infection) caused by polypharmacy (multiple drug use).
47. The toxicology report found there had likely been therapeutic range use of
amitriptyline, diazepam, promethazine, propranolol, methadone and tapentadol. (All
had been prescribed to Ms Perfect apart from tapentadol (an opioid pain killer).)
The report concluded that the combination of drugs present could increase sedation
and therefore the risk of aspiration pneumonia.
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Findings
Drugs strategy
48. Ms Perfect’s toxicology report noted that she had tapentadol in her system. The
prison does not prescribe tapentadol and therefore, it must have been smuggled in
from outside. It is unclear how Ms Perfect obtained it.
49. HMIP’s last inspection of Peterborough (Women) found that the availability of illicit
drugs was comparable to other women’s prisons, but the positive drug test rate was
low at 5.95%. Inspectors noted that some important steps had been taken to reduce
supply, including photocopying of mail and enhanced gate security, but that like all
women’s prisons, there was no body scanner to detect secreted items which was a
risk.
50. At the time of the HMIP inspection, the prison’s drug supply action plan was the
same across the men’s and women’s prisons and did not focus on supply specific to
the female population, such as the trading of medication. Peterborough has since
published a drug strategy for the women’s prison in December 2024. While it says
that diversion of medication is the most significant drug-related issue among female
prisoners, it does not say how this issue will be tackled. We would expect this to be
addressed within the drugs strategy, especially given its significance within the
women’s prison. We bring this to the Director’s attention.
Clinical care
51. The clinical reviewer considered that the clinical care Ms Perfect received was of a
good standard and was equivalent to that which she could have expected to receive
in the community. She found that Ms Perfect was monitored in line with the SMS
process, prescribed appropriate detoxification medications and assessed regularly
for withdrawal. She made no recommendations.
52. The clinical reviewer was satisfied that the prescribing of Ms Perfect’s medications
was in line with guidance. Ms Perfect had not been prescribed tapentadol, which
she had taken alongside her other medications.
Director to Note
53. Ambulance staff noted that they were delayed in getting to Ms Perfect due to having
to go through numerous locked gates. It made no difference in this case as Ms
Perfect was dead when found but delays could make a difference in a future
medical emergency. We bring this issue to the Director’s attention as it is the
prison’s responsibility to ensure swift access of emergency vehicles.
Inquest
54. At the inquest, held on 29 June 2026, the jury concluded that Ms Perfect’s death
was drug related.
Prisons and Probation Ombudsman 7
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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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