Keith Saunders

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Independent investigation into
the death of Mr Keith Saunders,
a prisoner at HMP
Peterborough, on 1 January
2023
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 HMPPS in ensuring the standard of care received by those within
service remit if appropriate then our recommendations should be focused, evidenced and
viable. This is especially the case if there is evidence of systemic failure.
Mr Keith Saunders died of infective exacerbation of COPD and ischaemic heart disease on
1 January 2023 at HMP Peterborough. He was 75 years old. I offer my condolences to his
family and friends.
The clinical reviewer concluded that the healthcare Mr Saunders received at Peterborough
was partially equivalent to that which he could have expected to receive in the community.
She was concerned that the care plans created to manage Mr Saunders’ COPD and
asthma were not reviewed until two years after his arrival at Peterborough. She was also
concerned that in the days leading up to Mr Saunders’ death his NEWS2 score (National
Early Warning Score) and oxygen saturation levels were not regularly recorded, and that
Mr Saunders was not referred to a GP for urgent review when his NEWS2 score indicated
that his health had deteriorated.
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 July 2023
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Contents
Summary ......................................................................... Error! Bookmark not defined.
The Investigation Process ................................................................................................ 1
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 9
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Summary
Events
1. On 12 September 1995, Mr Keith Saunders was charged with the manslaughter. He
was sent to HMP Maidstone.
2. Mr Saunders had several pre-existing medical conditions, including asthma and
COPD (chronic obstructive pulmonary disease, the name given to a range of
respiratory conditions), chest pain and hypertension (raised blood pressure).
3. Mr Saunders was released from prison and was recalled on two occasions for
breaching his licence conditions. He was last recalled to prison on 29 June 2016
and was sent to Peterborough prison.
3. A prison nurse carried out an initial health screen and noted his previous medical
conditions. She also noted that he had limited mobility and used a wheelchair and a
walking stick to move around. Healthcare staff created care plans to manage his
care, and he was referred to the prison’s older prisoner and long-term conditions
clinics.
4. While at Peterborough, Mr Saunders was admitted to hospital on several occasions
for exacerbation of COPD, an irregular heart rate and hospital acquired pneumonia.
5. At 3.30pm on 1 January 2023, a prisoner approached a Prison Custody Officer
(PCO) and told him that he had seen Mr Saunders lying on the floor of his cell, and
that he appeared extremely unwell. The PCO went to the cell immediately. He
called Mr Saunders’ name, but he did not respond. The PCO radioed a medical
emergency code and staff in the prison control room telephoned for an emergency
ambulance immediately.
6. More staff arrived at Mr Saunders’ cell, and they started cardiopulmonary
resuscitation (CPR) while they waited for the arrival of paramedics. At 3.38pm, the
paramedics arrived and took over Mr Saunders’ care and treatment. At 4.19pm,
they confirmed that Mr Saunders had died.
7. The post-mortem report gave Mr Saunders’ cause of death as infective
exacerbation of COPD and ischaemic heart disease.
Findings
8. The clinical reviewer concluded that the healthcare Mr Saunders received at
Peterborough was partially equivalent to that which he could have expected to
receive in the community.
9. She found that the care plans created to manage Mr Saunders’ COPD and asthma
were not reviewed until two years after he arrived at Peterborough. In the days
leading up to Mr Saunders’ death his NEWS2 score (National Early Warning Score)
and oxygen saturation levels were not recorded regularly, and a nurse did not refer
Mr Saunders to a GP for further review as she should have done.
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Recommendations
• The Head of Healthcare should review the pathway for long-term conditions to
ensure compliance with NICE clinical guidance.
• The Head of Healthcare should ensure:
• healthcare staff routinely record the NEWS 2 score when completing clinical
observations on acutely unwell patients, to aid the prompt and timely recognition
of deterioration; and
• NEWS2 threshold triggers are adhered to across the service as per NICE
MIB205 (Medtech innovation briefing 205)
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The Investigation Process
10. HM Prison and Probation Service notified us of Mr Saunders’ death on 1 January
2023. The investigator issued notices to staff and prisoners at HMP Peterborough
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Saunders’ prison and
medical records.
12. NHS England commissioned a clinical reviewer to review Mr Saunders’ clinical care
at the prison.
13. We informed the Coroner for Cambridgeshire and Peterborough of the investigation
who gave us the results of the post-mortem examination. We have sent the coroner
a copy of this report.
14. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
15. The Ombudsman’s family liaison officer wrote to Mr Saunders’ next of kin, his
friend, to explain the investigation and to ask if he had any issues he wished the
investigation to consider. He did not respond to her letter.
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Background Information
HMP Peterborough
16. HMP/YOI Peterborough is operated by Sodexo Justice Services. It holds men and
women in separate sides of the prison. There is 24-hour healthcare provision. All
healthcare is provided by Sodexo under the provisions of their contract with the
Ministry of Justice.
HM Inspectorate of Prisons (HMIP)
17. The most recent inspection of HMP Peterborough was in November 2018.
Inspectors reported that Peterborough had maintained strong clinical leadership
and adequate staffing levels despite some challenges. They found that several
aspects of health care provision had improved following the last inspection.
Inspectors reported that the healthcare unit had a more clinical focus with prisoners
placed there for clinical rather than operational reasons and found that clear care
plans were in place.
Independent Monitoring Board
18. 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 March 2022, the IMB reported
that clinical, mental health and drug services were not providing an adequate
service. They noted that the steps needed to contain and the risk of the spread of
COVID-19, had put additional pressure on the prison’s healthcare staff and that
against a backdrop of change healthcare staff did their best to provide the full range
of services required.
19. The IMB also noted that many prisoners continued to report that they were
dissatisfied with the healthcare services the prison provided. To ensure that
healthcare standards were maintained and improved, the IMB said that
Peterborough should prioritise reviewing and monitoring healthcare related
complaints.
Previous deaths at HMP Peterborough
20. Mr Saunders was the fourteenth prisoner to die at Peterborough since January
2020. Of the previous deaths, nine were from natural causes, two were self-inflicted
and two were drug related. There have been three further deaths since Mr
Saunders’ death two were from natural causes and one awaiting classification.
There are no significant similarities between our findings in this investigation and
those of the other deaths.
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Key Events
21. On 12 September 1995, Mr Keith Saunders was charged with the manslaughter of
his wife. He was sent to HMP Maidstone.
22. Mr Saunders had several pre-existing medical conditions, including asthma, COPD,
chest pain and raised blood pressure.
23. On 1 June, Mr Saunders was released on licence. He was recalled to prison in
October 2008, for breaching the conditions of his licence. Over the years that
followed, he transferred between establishments on a number of occasions, until he
was re-released in April 2016. However, a few months later, he was recalled to
prison for breaching his licence conditions, and he was sent to Peterborough.
HMP Peterborough
24. A nurse completed an initial health screen. She noted Mr Saunders’ medical
conditions and also that he had mobility issues and used a wheelchair and a
walking stick to move around. The nurse considered that due to his poor physical
condition, he would benefit from being admitted to the prison’s healthcare inpatient
unit for closer observation. Mr Saunders refused and signed a disclaimer to that
effect. The nurse created care plans to manage his conditions. Over the years that
followed, healthcare staff and secondary care providers reviewed Mr Saunders
regularly. He was admitted to hospital on several occasions to receive treatment for
exacerbation of his COPD.
25. In 2021, Mr Saunders was taken to hospital and admitted as an inpatient on three
occasions to receive treatment for a hernia (a condition in which part of the stomach
squeezes up into the chest through an opening in the diaphragm), exacerbation of
COPD, a lower respiratory tract infection, hypomagnesemia (a low serum
magnesium level, often an indicator of chronic disease), and a fractured hip. Prison
healthcare staff continued to review him regularly.
2022
26. On 6 May 2022, a nurse saw Mr Saunders after prison officers were concerned that
he appeared confused and disorientated. She considered that he needed to be
reviewed at hospital and he was taken to Peterborough City Hospital by emergency
ambulance. Hospital staff diagnosed him with a chest infection and an erratic heart
rate. He was admitted to hospital as an inpatient and treated with intravenous
antibiotics and oxygen therapy. His condition improved and he was discharged back
to the prison on 12 May.
27. On 12 July, a GP at the prison saw Mr Saunders. He noted that Mr Saunders
appeared extremely unwell and that his breathing appeared laboured. He
considered he might have developed pneumonia and sent him to hospital by
emergency ambulance. Hospital staff diagnosed him with hospital acquired
pneumonia. He was admitted as an inpatient and treated with intravenous
antibiotics. He was discharged back to the prison on 20 July. Healthcare staff
reviewed him regularly over the months that followed.
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28. On 9 December, a nurse saw Mr Saunders after he complained of experiencing flu
like symptoms. She took a note of his observations, which were within a normal
range. Due to his recent bout of pneumonia, she suggested that he moved to the
healthcare inpatient unit for closer observation. Despite repeated encouragement,
he consistently refused. He was prescribed a course of antibiotics and told to rest.
She reviewed him again later that afternoon and noted that his condition had
improved.
29. On 24 December, a nurse attempted to review Mr Saunders after he complained of
chest pain. Before she could do so, he told her that he wanted nothing to do with
healthcare and that he would call for assistance if he needed it. The following day, a
nurse saw Mr Saunders and encouraged him to take his medications, but he
refused. She took a note of his observations and considered that he might have
developed sepsis. She telephoned for an emergency ambulance and was told that
the waiting time would be two and a half hours. When paramedics arrived at the
prison, they diagnosed Mr Saunders with a chest infection and considered he would
benefit from admission to hospital for closer observation. However, despite
repeated encouragement, Mr Saunders refused to go. Paramedics asked that he be
prescribed antibiotics. Two days later, a nurse saw him again and noted that his
condition had improved and that he was taking his medications.
30. Later that day, a nurse also saw Mr Saunders. She noted his respiratory rate and
blood pressure were within a normal range, but that his temperature was raised and
that his oxygen saturation level was low. She made a note in his medical records
and asked for a nurse on night duty to carry out a further review. Another nurse saw
Mr Saunders in the early hours of the following morning. She noted his
observations, which were within a normal range. She did not record his oxygen
saturation level, or make a note of his NEWS2 score, despite his oxygen saturation
level being recorded as low the previous day.
31. On 30 December, a nurse took a note of Mr Saunders’ observations. She noted
they were all within range except for his oxygen saturation level, which was low.
She recorded his NEWS2 score as three. (A score of three requires an urgent
review by a GP to consider if an escalation of clinical care or review by hospital staff
is necessary.) There is no recorded evidence in his medical record to indicate that
she referred him to a prison GP for urgent review.
32. The following day, a nurse saw Mr Saunders. He told her that he was experiencing
a shortness of breath, which had not improved when he used his inhaler. She noted
that Mr Saunders did not appear to have a cough and that he was able to speak in
full sentences. She told him that she would review him again, but that he should ask
for assistance should he feel the need. At 9.56am the following morning, she
reviewed him again and noted that his condition had improved. She took a note of
his observations, which she recorded as within a normal range.
6 Prisons and Probation Ombudsman
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Events of 1 January 2023
33. At 3.30pm on 1 January 2023, a prisoner approached PCO A and told him that he
had seen Mr Saunders lying on the floor of his cell and that he appeared extremely
unwell. The PCO immediately attended the cell. He called Mr Saunders’ name, but
he did not respond. He radioed a code blue (indicating a prisoner is unconscious or
is having breathing difficulties). Staff in the prison control room telephoned for an
emergency ambulance immediately.
34. PCO B responded to the code blue. When he arrived at the cell, he assisted PCO A
to turn Mr Saunders onto his back and to check for signs of life, but there were
none. They noticed blood on the floor, but it was not clear where the blood had
come from. PCO B radioed a code red (indicating a prisoner is bleeding). Another
PCO arrived shortly afterwards and cleared the landing outside of Mr Saunders’
cell.
35. A nurse arrived shortly afterwards, accompanied by two more nurses, who brought
an emergency grab bag. They moved Mr Saunders out of his cell and began CPR.
The nurse attached a defibrillator to Mr Saunders’ chest, but no shockable rhythm
was found. He then inserted a cannula into Mr Saunders’ wrist and an i-gel into his
airway (a device used to open the airway to aid resuscitation).
36. At 3.38pm, the paramedics arrived at the cell and took over Mr Saunders’ care and
treatment. At 4.19pm, a paramedic confirmed that Mr Saunders had died.
Contact with Mr Saunders’ family
37. On 1 January 2023, the prison appointed a Family Liaison Officer (FLO). He
attempted to contact Mr Saunders’ daughter to inform her of her father’s death.
However, the telephone number listed on Mr Saunders’ prison records was
incorrect. He then telephoned Mr Saunders’ brother to ask if he had an up-to-date
telephone number for Mr Saunders’ daughter. He did not but said that Mr Saunders
also had a son who may have had her current telephone number, and that he would
try and contact him.
38. On 3 January, the FLO telephoned Mr Saunders’ friend, who he had listed as his
next of kin. He informed him of Mr Saunders’ death and offered his support. Two
days later, the FLO telephoned Mr Saunders’ brother to ask if he had managed to
obtain a number for Mr Saunders’ daughter. He told the FLO that Mr Saunders’ son
did not have any contact details for his sister. He informed him of his brothers’
death and offered him support. The FLO remained in contact with Mr Saunders’
brother offering him support.
39. The prison contributed towards the cost of his funeral in line with national guidance.
Support for prisoners and staff
40. After Mr Saunders’ death, welfare checks were offered to the staff involved in the
emergency response. There is no evidence that managers held a post-incident
debrief.
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41. The prison posted notices informing other prisoners of Mr Saunders’ 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 his death.
Post-mortem report
42. The post-mortem report gave Mr Saunders’ cause of death as infective
exacerbation of COPD and ischaemic heart disease.
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Findings
Clinical care
43. The clinical reviewer concluded that the care Mr Saunders received at HMP
Peterborough was only partially equivalent to that which he could have expected to
receive in the community.
44. She did note, however, that healthcare staff managed Mr Saunders with a high level
of compassion and care, even though he sometimes displayed challenging and
difficult behaviour.
Care plans
45. The clinical reviewer noted that when Mr Saunders arrived at Peterborough,
healthcare staff recorded that he had care plans in place to manage his COPD and
asthma. However, she found that those care plans were not updated until two years
after he arrived at the prison, contrary to NICE guidance NG80. She considered that
the two-year gap between reviewing his care plans could have had a negative effect
on the long-term management of his care. We recommend:
The Head of Healthcare should review the pathway for long-term conditions
to ensure compliance with NICE clinical guidance.
Use of NEWS2 scores
46. On 27 December, a nurse saw Mr Saunders and noted his observations, which she
recorded as all being within a normal range. However, she did not record his
oxygen saturation level, nor did she make a note of his NEWS2 score, despite his
oxygen saturation level being recorded as low and of concern the previous day.
Also on 30 December, a nurse did not refer Mr Saunders to a GP for review. She
should have done after his NEWS 2 score indicated that he should be seen
urgently. This was a missed opportunity to identify the extent to which Mr Saunders’
health was deteriorating. We recommend:
The Head of Healthcare should ensure
• healthcare staff routinely record the NEWS 2 score when completing
clinical observations on acutely unwell patients, to aid the prompt and
timely recognition of deterioration; and
• NEWS2 threshold triggers are adhered to across the service as per NICE
MIB205 (Medtech innovation briefing 205)
47. The clinical reviewer made recommendations about record keeping, which we do
not repeat in this report, but which the Head of Healthcare will need to address.
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Inquest
At the inquest held on 29 February 2024, the coroner concluded Mr Saunders died of
natural causes.
10 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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