Norman Heaton

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Norman Heaton,
a prisoner at HMP Full Sutton,
on 2 November 2025
A report by the Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concern
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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. In May 2002, Mr Norman Heaton was sentenced to life imprisonment for murder.
He received a minimum tariff of 10 years 11 months. He died of Bronchopneumonia
on 2 November 2025, at HMP full Sutton. He was 66 years old. We offer our
condolences to Mr Heaton’s family and friends.
4. The Ombudsman’s office wrote to Mr Heaton’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
5. NHS England commissioned an independent clinical reviewer to review Mr
Heaton’s clinical care at HMP Full Sutton. The clinical reviewer’s report is attached
as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Heaton received at Full
Sutton was of a good standard and equivalent to what he could have expected to
receive in the community. She found that the care Mr Heaton received whilst on the
palliative care suite at Full Sutton was kind, compassionate, timely and appropriate.
There was excellent multidisciplinary collaboration between the prison and external
health services, and evidence documented within Mr Heaton’s medical records of
timely referrals, DNACPR discussions and advance care planning. The clinical
reviewer made one recommendation not related to Mr Heaton’s death that the Head
of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Heaton’s
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Adrian Usher March 2026
Prisons and Probation Ombudsman
Inquest
10. At the inquest held on 29 June 2026, the coroner concluded that Mr Heaton died of
natural causes.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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