John Freer

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr John Freer,
a prisoner at
HMP Northumberland,
on 29 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, 2025
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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 1 July 2024, Mr John Freer was sentenced to 14 months in prison for breaching
his licence conditions (accessing a laptop and smartphone to stalk his victim). He
died of metastatic adenocarcinoma of the lung on 29 October 2024, while a prisoner
at HMP Northumberland. He was 45 years old. We offer our condolences to Mr
Freer’s family and friends.
4. The Ombudsman’s office contacted Mr Freer’s next of kin to ask if they had any
matters, they wanted us to consider. Mr Freer’s next of kin declined the offer of
engagement.
5. The PPO investigator investigated the non-clinical issues relating to Mr Freer’s
care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Mr Freer’s
clinical care at Northumberland.
7. The clinical reviewer concluded that the clinical care Mr Freer received at
Northumberland was of a variable standard and only partially equivalent to what he
could have expected to receive in the community. She found that Mr Freer’s
medical records contained evidence of excellent individualised end of life care
engagement. However, we make the following recommendation related to Mr
Freer’s cause of death:
The Head of Healthcare at HMP Northumberland should review the care
management of patients with a cancer diagnosis. This should include
ensuring each patient has an identified lead nurse who will oversee the
implementation of a plan of care, including advance care planning
discussions and DNACPR discussions, in line with the national framework,
Dying well in custody charter.
8. The clinical reviewer made other recommendations not related to Mr Freer’s cause
of death which the Head of Healthcare will wish to address.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS and Spectrum CIC did not find any factual inaccuracies.
10. At the inquest held on 27 May 2025, the coroner concluded that Mr John Freer died
of natural causes.
Adrian Usher
Prisons and Probation Ombudsman April 2025
Prisons and Probation Ombudsman 1
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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
OFFICIAL - FOR PUBLIC RELEASE