Patrick Horner

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Independent investigation into
the death of Mr Patrick Horner,
on 21 December 2024, following
his release from HMP Leeds
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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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. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
3. 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.
4. Mr Patrick Horner died from a pulmonary embolism (when a blood vessel in the
lungs is blocked by a blood clot). This was caused by sepsis which was in turn
caused by cellulitis (a bacterial infection in the deep layers of the skin). He died on
21 December 2024 following his release from HMP Leeds on 17 December. He was
76 years old. We offer our condolences to those who knew him.
5. The clinical reviewer concluded that the care Mr Horner received at Leeds was of a
good standard and was equivalent to that which he could have expected to receive
in the community. She did not make any recommendations.
6. We did not identify any significant learning relating to the pre-release planning for or
post-release supervision of Mr Horner.
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The Investigation Process
7. HMPPS notified us of Mr Horner’s death on 23 December 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Horner’s prison
and probation records.
9. NHS England commissioned an independent clinical reviewer to review Mr Horner’s
clinical care at the prison.
10. We informed HM Coroner for West Yorkshire of the investigation. She told us that
Mr Horner’s death had not been referred to them and there would not be an inquest
as he had died of natural causes in the community.
11. The Ombudsman’s office contacted Mr Horner’s next of kin, his daughter, to explain
the investigation and to ask if she had any matters she wanted us to consider. She
had the following concerns and questions:
• She asked about an incident which took place on 31 October 2024, where
she said Mr Horner was subjected to an invasive rectal examination and was
forced to have a ‘buzz cut’.
• Did Mr Horner have access to a walking stick/mobility aid at HMP Leeds?
• Was Mr Horner appropriately located while at HMP Leeds?
• Should Mr Horner have been moved to H Wing sooner?
• Why did he have a neurological scan and an MRI scan?
• Did Mr Horner attend any classes or activities where his memory could be
observed?
• Why was supported accommodation not arranged before his release?
• Why was Mr Horner released to accommodation that was not suited to his
needs? For example, it was not a secure room, it had a heavy door, the TV
did not work, the sofa was too low for him to sit on, there was no shower and
it was on the first floor with steep stairs.
• Why did social services only visit him three times a day for half an hour?
• What did the carers observe when they visited Mr Horner?
• Why was his release not delayed until a safe place was available for him?
Her concerns have been addressed in the clinical review, in this report and by
separate correspondence.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one factual inaccuracy and this report has been amended
accordingly.
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Mr Horner’s family received a copy of the draft report. They did not make any
comments.
Background Information
HMP Leeds
13. HMP Leeds is a category B reception and resettlement prison in Leeds, Yorkshire.
Practice Plus Group provides healthcare services, including mental health services
and substance misuse services.
Probation Service
14. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriate. Post-release, the Probation Service supervises people throughout their
licence period and post-sentence supervision.
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Key Events
Background
15. On 18 June 2024, Mr Patrick Horner was convicted of sex offences and was
sentenced to 12 months in prison. He was sent to HMP Leeds.
16. Mr Horner had a history of asthma, chronic obstructive pulmonary disease (COPD),
high blood pressure and heart disease. While in prison, he was diagnosed with
prostate cancer.
Pre-release planning
17. On 21 June, an officer from the prison’s resettlement team saw Mr Horner who told
him he lived alone in private rented accommodation. The officer completed a
referral to the Commissioned Rehabilitative Services (CRS, a probation service
which aims to help break the cycle of reoffending by providing guidance, support
and practical help to tackle the barriers to rehabilitation) to arrange for the tenancy
to be maintained while Mr Horner was in custody. The referral was sent to St Giles
Trust. Mr Horner told the officer that he had multiple health conditions, and that he
was registered with a GP in the community.
18. On 11 July, Mr Horner attended an appointment with St Giles Trust. Mr Horner’s
Community Offender Manager (COM) told us that the referral was closed following
this meeting at Mr Horner’s request as there were plans for his daughter to manage
the property while he was in prison.
19. On 17 July, a GP operating at Leeds, saw Mr Horner. She noted that he had
oedema (swelling) in both legs, which Mr Horner reported was longstanding.
20. On 16 October, a Nurse saw Mr Horner. She noted that he had some foot and ankle
oedema. She advised him to elevate his legs. Mr Horner told her that he would see
a GP on release for follow-up care.
21. On 29 October, Mr Horner’s Prison Offender Manager (POM), saw Mr Horner for a
planned supervision session. Mr Horner signed a medical consent form which
stated that he was happy for the COM and herself to receive relevant information
from healthcare staff to help plan for his release.
22. On 5 November, an officer from the prison’s resettlement team saw Mr Horner to
discuss his accommodation plans for release. A COM told us that Mr Horner’s
daughter said that when she attended Mr Horner’s previous address, it was a
complete mess. As Mr Horner had not been looking after it, she was asked to take
his belongings and he was not allowed back there.
23. On 6 November, a nurse saw Mr Horner. It is noted that he was struggling with daily
tasks so was relocated within the prison to receive social care support (local
authority provided carers to help with daily living tasks).
24. On 7 November, a COM completed another CRS referral to St Giles Trust to
arrange accommodation for Mr Horner’s release.
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25. On 15 November, a COM referred Mr Horner to both York Council and Leeds
Council for accommodation under the statutory duty to refer those at risk of
homelessness. Both councils later responded that they could only offer a rough
sleeper hostel accommodation and that there was a two to three year waiting list for
permanent accommodation.
26. On 19 November, a COM referred Mr Horner to be considered for an approved
premises (AP). This was later rejected as Mr Horner was deemed unsuitable for an
AP due to his health and social care needs.
27. On 20 November, a nurse and COM exchanged emails about finding suitable
accommodation for Mr Horner. A nurse completed an adult social care referral to
Leeds City Council. A COM completed a referral to HMPPS’ Community
Accommodation Service Tier 3 (CAS3, a service open to adult prison leavers at risk
of homelessness on release from prison. The service provides access to up to 84
days of accommodation). This was completed as an emergency option due to there
being no success with the local councils or other housing services.
28. On 22 November, a nurse emailed Leeds Adult Social Care. They informed her that
they would be able to arrange a package of care if Mr Horner had an address to
which he would be released. It is recorded that both the nurse and COM had
explored all options but were unable to secure a fixed address for Mr Horner.
29. On 25 November, a COM referred Mr Horner to NHS Reconnect (a care after
custody service which aims to improve the continuity of healthcare after release
from prison). The referral was accepted.
30. That day, a GP operating at Leeds saw Mr Horner and they discussed his leg
oedema. Mr Horner told him that he was not concerned about his legs, and the GP
found no evidence of deterioration.
31. On 27 November, a nurse phoned York Council about a home placement in York
for Mr Horner, and they asked her to complete a duty to refer form. She also sent
Mr Horner’s social care assessment to York Council. She recorded that Mr Horner
was happy to explore options to live in York. She also completed a six-item
cognitive impairment test (6CIT) with Mr Horner after his daughter raised concerns
about him having dementia. The results did not indicate memory impairment.
32. On 28 November, Reconnect assessed Mr Horner. A Healthcare Assistant (HCA)
also saw Mr Horner and it was noted that his legs were very swollen and red. The
HCA took observations and Mr Horner’s National Early Warning Score (NEWS2)
score was 0 which indicated that he was not at risk of clinical deterioration.
33. On 29 November, a GP saw Mr Horner due to ongoing concerns about leg swelling.
Mr Horner told him that it had not got worse recently. The GP recorded in the
medical records that Mr Horner had warm legs but there were no obvious signs of
cellulitis. He told Mr Horner to keep his legs elevated and to seek help if he had any
new or worsening symptoms. He prescribed a course of antibiotics.
34. On 5 December, a nurse had a phone call with York Council and Mr Horner. The
council said that there was a large waiting list for a permanent property in York, and
they could only offer Mr Horner a space at a homeless hostel or a crash bed
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(described as a mattress on the floor in a place of warmth and safety) in the
meantime. She explained that a crash bed would be highly inappropriate for Mr
Horner due to his age and health.
35. On 10 December, a CAS3 property was arranged for Mr Horner in Leeds. A COM
informed the accommodation provider of Mr Horner’s needs, and it was confirmed
that social services could visit him daily.
36. On 11 December, a COM emailed a nurse and gave her the CAS3 address for Mr
Horner’s release. The nurse completed a referral to Leeds Council to arrange a
social care package. Healthcare staff sent Mr Horner a letter and a form to help him
register with a GP on release.
37. On 12 December, Mr Horner’s medication was arranged for his release. A POM
saw Mr Horner to discuss his CAS3 accommodation. He confirmed that he had
already been notified that he was being released to temporary accommodation in
Leeds and that he understood the reasons for this, despite requesting
accommodation in York. He was given and signed a copy of the CAS3 compact.
38. On 13 December, a nurse phoned Leeds Council and gave them the details of the
care he had received in prison so that a mirrored package of care could be set up.
Release from HMP Leeds
39. On 17 December, a nurse saw Mr Horner in reception before release and he was
given his medication to take with him. He was given details about how to access
further medication. He declined help to register with a GP practice. Reception staff
gave him a clothing parcel, toiletries and arranged for a taxi to take him to the
probation office.
40. Mr Horner attended his probation induction with a COM. As Mr Horner said that he
was hungry, the COM went to a food bank and got some meals for him to eat that
evening. Further meals were to be provided as part of his social care package. The
COM explained Mr Horner’s licence conditions to him and arranged to call him as
he would not easily be able to attend the probation office in his condition. CAS3
staff picked Mr Horner up from the office and took him to the CAS3 accommodation.
41. Later that day, the CAS3 Resident Welfare Officer emailed a COM and raised
concerns about the property as it was on the first floor, and they were concerned
about whether Mr Horner could manage the stairs. The COM passed this
information to her Senior Probation Officer (SPO).
42. On 18 December, a COM had an email exchange with the Resident Welfare Officer
about Mr Horner’s CAS3 property. She recorded that she was going to look for
alternative accommodation on the ground floor and contacted charities to see if they
could offer Mr Horner support.
43. On 20 December, the CAS3 Resident Welfare Officer emailed a COM and told her
that Mr Horner had been admitted to hospital with cellulitis of his legs.
44. The COM continued to explore alternative accommodation for Mr Horner. She
recorded that there were no CAS3 properties available in Leeds or in the areas near
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Leeds. Due to the social care package arranged, she did not want to widen the
search further.
Circumstances of Mr Horner death
45. On 21 December, the police notified the Probation Service that Mr Horner had died
in hospital.
Cause of death
46. A post-mortem examination was not carried out as the Coroner accepted the cause
of death provided by a hospital doctor. The doctor gave the cause of death as a
pulmonary embolism caused by sepsis, which was in turn caused by cellulitis.
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Findings
Clinical care
47. The clinical reviewer concluded that the care Mr Horner received during his time at
Leeds and before his release into the community was of a good standard and was
equivalent to that which he could have expected to receive in the wider community.
48. She found that Mr Horner’s care was in line with guidance, and he had the
appropriate care plans in place. She also concluded that his ongoing health
concerns were addressed, and the healthcare team responded promptly and
proactively to his needs.
49. The clinical reviewer found that the healthcare team planned for Mr Horner’s
release well in advance by liaising with the appropriate agencies and sharing
information about his risks and needs. She made no recommendations.
Accommodation
50. The provision of suitable accommodation for people leaving prison is an issue that
extends beyond the remit of Leeds or local probation services. A COM suitably
prepared for Mr Horner’s release by promptly completing accommodation referrals
to the local authorities. However, it is unfortunate that the local authorities were
unable to provide suitable accommodation.
51. The Regional Homelessness Prevention Team Coordinator told us that given the
limited options, the CAS3 accommodation was the most suitable arrangement that
could have been made for Mr Horner. He said that he felt the Homeless Prevention
Team and Probation Service did everything within their capacity to support Mr
Horner in the CAS3 property.
52. We appreciate that the CAS3 accommodation arranged for Mr Horner did not meet
all his needs. However, we are satisfied that the COM and nurse did everything
they could to arrange suitable accommodation for his release and it was unfortunate
that the CAS3 temporary accommodation was the only feasible option available to
him at the time.
Good Practice
53. Although Mr Horner’s housing situation on release was not ideal, we consider that
the nurse and COM took extensive steps to identify suitable accommodation for Mr
Horner. They were proactive and responsive to his needs. We consider their actions
to be examples of good practice.
Adrian Usher
Prisons and Probation Ombudsman August 2025
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