Leslie Moulden

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Independent investigation into
the death of Mr Leslie Moulden,
a prisoner at
HMP Northumberland,
on 26 March 2022
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. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr Leslie Moulden died in hospital of oesophageal cancer on 26 March 2022, while
a prisoner at HMP Northumberland. He was 62 years old. We offer our condolences
to Mr Moulden’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Moulden received at
Northumberland was equivalent to that which he could have expected to receive in
the community.
5. We found no non-clinical issues of concern. We make no recommendations.
Prisons and Probation Ombudsman 1
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The Investigation Process
6. NHS England commissioned an independent clinical reviewer to review Mr
Moulden’s clinical care at HMP Northumberland.
7. The PPO investigator investigated the non-clinical issues relating to Mr Moulden’s
care, including Mr Moulden’s location, the security arrangements for his hospital
escorts, liaison with his family and whether compassionate release was considered.
8. The PPO family liaison officer wrote to Mr Moulden’s next of kin, his daughter, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She did not respond.
9. We shared our initial report with HM Prison and Probation Service (HMPPS). They
identified one minor factual inaccuracy, which has been amended in this report.
Previous deaths at HMP Northumberland
10. Mr Moulden was the eleventh prisoner to die at Northumberland since March 2020.
Of the previous deaths, six were from natural causes, three were self-inflicted and
one was drug related.
2 Prisons and Probation Ombudsman
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Key Events
11. In January 2019, Mr Leslie Moulden was sentenced to 16 years in prison for drug
offences. On 9 March 2020, he was moved to HMP Northumberland.
12. On 14 July, a prison GP saw Mr Moulden as he was having difficulty swallowing
certain types of food. She increased his medication to reduce stomach acid and
noted she would review him again in two weeks.
13. The next day, Mr Moulden told staff he had been coughing up blood and they made
him an urgent appointment with a nurse. She arranged urgent blood tests. A prison
GP reviewed the blood test results the next day. He noted they were normal and
asked for them to be repeated in a week. He referred Mr Moulden for a chest X-ray.
14. On 17 July, Mr Moulden attended hospital for his chest X-ray. The hospital also
carried out a procedure to examine his oesophagus (also called the gullet or food
pipe, it connects the mouth to the stomach). The results showed that Mr Moulden
was likely to have cancer. Mr Moulden discharged himself from hospital that
evening. When he returned to Northumberland, he told staff he had been diagnosed
with stomach cancer, did not have long left to live and would not be having any
treatment.
15. In August, Mr Moulden agreed to attend a hospital appointment to discuss his
treatment. He was formally diagnosed with cancer of the oesophagus, and it was
agreed that he would have a course of chemotherapy followed by surgery. He
started chemotherapy treatment on 19 November.
16. Mr Moulden was given a pre-operative assessment appointment for 11 February
2021, but the prison healthcare department only received the appointment letter
that morning. Mr Moulden already had a hospital appointment at another clinic at a
different hospital, which he was taken to as scheduled. The pre-operative
assessment appointment was rearranged for 17 February, which Mr Moulden
attended.
17. On 26 February, Mr Moulden had surgery to remove some of the cancer in his
oesophagus. He was discharged back to Northumberland on 6 April. The plan had
been for him to be discharged to HMP Holme House, which has 24-hour healthcare,
but Mr Moulden wanted to go back to Northumberland as it was easier for his family
to visit him there.
18. Mr Moulden had a feeding tube in place and could eat a soft diet, which the prison
kitchen provided. However, Mr Moulden struggled to eat much.
19. On 16 April, a prison GP sent Mr Moulden to hospital as he was dizzy, short of
breath and had diarrhoea. He was admitted. On 26 April, a hospital consultant told
Mr Moulden that further chemotherapy was not an option due to the progression of
the cancer. He returned to Northumberland the same day.
20. On 4 June, Mr Moulden was admitted to hospital after his feeding tube had come
out during the night while he was asleep. He was discharged on 1 July to HMP
Holme House as he had lost a considerable amount of weight. Mr Moulden returned
to Northumberland on 7 September, following a small improvement in his weight.
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21. On 31 January 2022, a prison nurse completed observations on Mr Moulden, as he
had been feeling unwell over the previous few days. She spoke with the prison GP,
who agreed that Mr Moulden should be taken to hospital for further assessment. Mr
Moulden was taken to hospital that morning and admitted.
22. On 1 February, a hospital consultant told Mr Moulden that he had widespread
cancer and it was likely that he had less than three months to live.
23. On 10 February, the prison submitted an application for Mr Moulden’s early release
on compassionate grounds to the Public Protection Casework Section (PPCS) of
HM Prison and Probation Service (HMPPS). PPCS refused the application due to
security concerns.
24. Mr Moulden’s condition continued to deteriorate while in hospital. On 22 March, the
prison resubmitted Mr Moulden’s application for release on compassionate grounds,
with an updated statement from a hospital doctor saying that Mr Moulden likely had
a few weeks left to live. This was not processed before he died.
25. Mr Moulden died in hospital on 26 March at 6.27am.
Post-mortem report
26. The post-mortem report concluded that Mr Moulden died of bronchopneumonia
caused by adenocarcinoma (cancer) of the oesophagus.
Louise Richards April 2023
Assistant Ombudsman
Inquest
The inquest, held on 18 June 2025, concluded that Mr Moulden died of natural causes.
4 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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