Peter Hines

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Independent investigation into
the death of Mr Peter Hines,
a prisoner at HMP Hewell, on 25
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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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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. In September 2024, Mr Peter Hines was sentenced to 27 months for burglary. He
died of cardiac amyloidosis on 25 October 2024, in hospital while a prisoner at HMP
Hewell. He was 65 years old. We offer our condolences to Mr Hines’ family and
friends.
4. The Ombudsman’s office wrote to Mr Hines’ next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Hines’ family
asked about the checks staff completed on Mr Hines, and whether his missed
hospital appointments affected his health negatively. These concerns have been
addressed in separate correspondence.
5. NHS England commissioned an independent clinical reviewer to review Mr Hines’
clinical care at HMP Hewell.
6. The clinical reviewer concluded that the clinical care Mr Hines received at Hewell
was of a good standard and equivalent to what he could have expected to receive
in the community. She found that despite healthcare staff offering unified support to
Mr Hines on several occasions, he would not engage. The clinical reviewer made
recommendations not related to Mr Hines’ death that the Head of Healthcare will
wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Hines’s
care. We did not find any non-clinical issues of concern.
8. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS/Practice Plus Group pointed out some factual inaccuracies, and this report
has been amended accordingly.
10. Mr Hines family received a copy of the initial report. They did not make any
comments.
Adrian Usher May 2025
Prison and Probation Ombudsman
At the inquest held on 2 June 2025, the coroner concluded Mr Peter Hines died from
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