Peter Hopkins

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Independent investigation into
the death of Mr Peter Hopkins,
a prisoner at HMP Doncaster,
on 12 December 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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© Crown copyright, 2026
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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. 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. Mr Peter Hopkins died of bilateral pneumonia (infection in both lungs) on 12
December 2024, while a prisoner at HMP Doncaster. Frailty and metastatic renal
cancer (cancer that started in the kidneys and then spread to other parts of the
body) contributed to but did not cause Mr Hopkins’ death. He was 84 years old. We
offer our condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Hopkins received at
Doncaster was partially equivalent to that which he could have expected to receive
in the community. She found that the healthcare team did not follow up with hospital
appointments, that there was a delay in referring Mr Hopkins to the multidisciplinary
forum (MPCCC) and that they did not identify Mr Hopkins’ risk of malnutrition. The
clinical reviewer made several recommendations, some of which we have included
below.
5. We also found that Mr Hopkins’ compassionate release application was delayed
due to staff being unclear about their own responsibilities and not being proactive in
completing the application.
Recommendations
• The Head of Healthcare should review the current Local Operational Procedure:
Outside Hospital Appointments and the live cancer tracker to seek assurance that
they are sufficiently robust, effective and fit for purpose. An audit should then be
completed within three months of the completion of the review.
• The Head of Healthcare and Lead GP should ensure that staff are aware of and
adhere to Local Operating Procedure for referral to MPCCC so that referrals are
completed in timely manner and staff report significant updates with the wider team.
• The Head of Healthcare should ensure that staff receive training in recognising and
managing prisoners at risk of malnutrition.
• The Director and the Head of Healthcare should review the ERCG application
process, ensuring that all staff are aware of their responsibilities and are tenacious
in obtaining the information needed.
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The Investigation Process
6. HMPPS notified us of Mr Hopkins’ death on 12 December 2024.
7. NHS England commissioned an independent clinical reviewer, to review Mr
Hopkins’ clinical care at Doncaster. The clinical review is attached as Annex 1.
8. The PPO investigator investigated the non-clinical issues relating to Mr Hopkins’
care. She interviewed one member of staff from Doncaster. The investigator and
clinical reviewer jointly interviewed three members of healthcare staff.
9. The Ombudsman’s office wrote to Mr Hopkins’ next of kin to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked about Mr Hopkins’ healthcare treatment in prison and the delays in applying
for his compassionate release. These issues are covered in this report and the
clinical review.
10. 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. The action plan has been annexed to this report.
11. Mr Hopkins’ family received a copy of the draft report. They did not make any
comments.
Previous deaths at HMP Doncaster
12. In the three years before Mr Hopkins’ death, there were 12 deaths at Doncaster. Of
the previous deaths, seven were from natural causes and five were self-inflicted.
We found a similar issue about delays in applying for compassionate release in a
previous investigation. There have been four deaths since that of Mr Hopkins up to
the end of April 2025. Three of these were due to natural causes and the other
cause of death is currently unascertained.
Early release on compassionate grounds (ERCG)
13. Early release on compassionate grounds is the means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from custody before their sentence has expired. A clear
medical opinion of life expectancy is required. The criteria for early release are set
out in the Early Release on Compassionate Grounds Policy Framework. Among the
criteria is that the risk of reoffending is expected to be minimal, further imprisonment
would reduce life expectancy, there are adequate arrangements for the prisoner’s
care and treatment outside prison, and release would benefit the prisoner and his
family. An application for early release on compassionate grounds must be
submitted to the Public Protection Casework Section (PPCS) of HM Prison and
Probation Service (HMPPS).
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Key Events
14. Mr Peter Hopkins was remanded to HMP Doncaster in November 2016, charged
with sexual offences. The following month, he was sentenced to an extended
sentence of 25 years imprisonment and 2 years on licence. Mr Hopkins appealed
and, in January 2017, his sentence was amended to 20 years imprisonment and 1
year on licence.
15. Mr Hopkins had several long-term conditions, such as diabetes, hypertension (high
blood pressure), osteoarthritis (inflammation to joints), oesophageal (food pipe)
ulcers, and difficulty in swallowing food, drink and sometimes saliva.
16. In October 2018, the hospital urology team (a specialist team which focus on the
urinary and reproductive systems) found a tumour in Mr Hopkins left kidney. This
looked like it could become cancerous, so he had regular scans to monitor it.
17. In March 2020, Mr Hopkins had a CT scan and healthcare staff noted that the
tumour had grown significantly, was cancerous and that the left kidney should be
removed. This happened in April.
18. Follow-up tests confirmed that the cancer had not spread to other parts of the body.
Mr Hopkins continued to be monitored by the urology department.
19. In November 2021, a specialist consultant advised that a follow up CT scan should
happen in December and, if there were no concerns, then Mr Hopkins should be
reviewed six months later. In December, the healthcare team at Doncaster received
a letter with the plan, but no CT scan appointment. Staff did not follow this up.
20. In March 2022, the urology team sent a letter to the healthcare team to say that Mr
Hopkins had missed his CT scan, but no other CT was scheduled. Again,
healthcare staff at Doncaster did not follow this up.
21. The urology department cancelled an appointment on 17 May due to the doctor
being unwell. The healthcare team received a new appointment on 27 June for 1
November. At this appointment, Mr Hopkins presented as well and asymptomatic.
The consultant organised a CT scan for 30 December, which the prison
subsequently rearranged to 17 January 2023, due to a lack of available escorting
staff. Mr Hopkins attended this appointment. The urology team did not share the
results with Mr Hopkins or healthcare staff at Doncaster. As such, they were not
aware that a small lung nodule (a growth which can be benign or cancerous) had
been identified in the scan.
22. In July, Mr Hopkins had another CT scan, which revealed multiple nodules in his
lungs. The results were only shared with healthcare staff at Doncaster on 13
November, although there is no evidence that staff chased the results before this
date. (The reason for the delay in the hospital’s communication with Doncaster falls
outside the remit of this investigation.) The hospital had scheduled Mr Hopkins an
appointment for 17 October but the prison was unaware of this. Dr A, GP, reviewed
the hospital letter on 13 November and sent a task to the administrative team
ensuring that Mr Hopkins attended his next urology appointment as he may have
metastatic cancer. She did not document this information in Mr Hopkins’ clinical
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record or refer Mr Hopkins to the multi professional complex case clinic (MPCCC –
a weekly multidisciplinary meeting to assist clinicians to decide on a plan of care).
23. Mr Hopkins attended a hospital appointment on 21 November, when staff told him
that the cancer had spread to his lungs. The specialist consultant said he would
refer Mr Hopkins to an oncology (cancer) specialist to discuss his treatment options.
When Mr Hopkins returned to prison, there is no evidence that a nurse saw him. It
is unclear if the escorting officers notified healthcare staff of his diagnosis.
24. The urology team wrote to healthcare staff on 14 December to confirm Mr Hopkins’
diagnosis and treatment plan. Staff were unaware of the diagnosis until Mr Hopkins’
sister called the prison to bring this to their attention, on 19 December, as they had
not read the letter. The Deputy Head of Healthcare referred Mr Hopkins to the
MPCCC.
25. On 30 January 2024, Mr Hopkins had an oncology appointment and hospital staff
discussed his treatment plan with him. He had a CT scan on 2 February and the
first cycle of treatment started in early March. He became more unwell and moved
to the social care unit in the prison on 4 April. On 16 April, hospital staff stopped the
treatment as Mr Hopkins had reacted badly to it. On 19 April, Officer A was
appointed as family liaison officer and rang Mr Hopkins’ family.
26. On 20 April, Mr Hopkins was admitted to hospital due to him deteriorating. Prison
staff were aware that Mr Hopkins was unwell and may die soon. Therefore, prison
staff started an application for Mr Hopkins’ early release on compassionate grounds
(ERCG).
27. On 23 April, Mr A, Head of Offender Management Delivery, who was collating the
evidence for the ERCG application, contacted Officer A and told her he had started
the application. The next day, Officer A explained this to Mr Hopkins’ next of kin. On
28 April and 1 May the next of kin requested updates on the application. On 2 May,
Officer A told them that they were still collating evidence for the application.
28. On 10 May, Mr Hopkins returned to Doncaster. On 11 June, healthcare staff
completed their section of the ERCG application.
29. On 26 June, Mr Hopkins had a telephone appointment with an oncology specialist
who considered that he was not fit enough for further treatment. The consultant
noted that if Mr Hopkins had further symptoms which needed controlling, input from
the palliative care team would be appropriate. Mr Hopkins was accompanied by a
healthcare support worker who did not update the wider team as they should have.
30. On 14 August, hospital staff informed the prison that Mr Hopkins had been
discharged from the oncology team. The healthcare team only updated their
paperwork on compassionate release at this point.
31. Mr A told the investigator that having collated all the necessary evidence for the
ERCG application, the Deputy Director said they could not support the application
because there was not a clear plan on where Mr Hopkins would live. Mr A
contacted the Public Protection Casework Section (PPCS) who process
applications, to ask if they needed a firm address and release plan prior to
submitting the application. On 21 August 2024, PPCS confirmed they did.
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32. On 17 September, Mr Hopkins agreed with healthcare staff that, given his declining
health, he should not be resuscitated if his heart and breathing stopped. Over the
following months, Mr Hopkins’ condition continued to deteriorate.
33. On 11 October, staff had a multidisciplinary meeting to discuss Mr Hopkins’ ERCG
application. The actions from that meeting were unclear, but the main concern
seemed to be disclosure of Mr Hopkins’ offences to any potential hospice and how
stringent licence conditions could be managed in that setting.
34. On 21 November, Nurse A assessed Mr Hopkins and noted that the level of oxygen
in his bloodstream was low, so she gave him oxygen therapy. She noted that Mr
Hopkins had a NEWS2 (a tool that helps healthcare staff to determine the urgency
of the situation) score of nine, which warranted an immediate transfer to hospital.
Staff facilitated this.
35. On 26 November, Mr Hopkins returned to Doncaster. His sister called healthcare
staff as she was concerned he was in pain. Staff scheduled an appointment for 2
December to review his pain and to consider prescribing anticipatory medication
(medicine which is often prescribed at the end of life in case distressing symptoms
develop).
36. On 28 November, Nurse B assessed Mr Hopkins and his NEWS2 score was five
(meaning that Mr Hopkins was at medium risk of deterioration and needed to be
urgently reviewed by a clinician with expertise in acute illness assessment). Staff
requested an ambulance and paramedics arrived several hours later. Mr Hopkins
refused to go to hospital and said he felt ‘fine’.
37. On 2 December, Dr B, GP, reviewed Mr Hopkins. He said he was not in pain or
discomfort. She assessed that Mr Hopkins did not need to be prescribed
anticipatory medication yet. She requested that healthcare staff monitor Mr Hopkins’
blood pressure.
38. On 4 December, healthcare staff assessed Mr Hopkins and his NEWS2 score was
five, so they called an ambulance and asked Mr Hopkins to eat and drink. Mr
Hopkins said he had no appetite. When paramedics arrived, they reiterated what
healthcare staff had said and assessed that Mr Hopkins did not need to go to
hospital.
39. Later that day, Dr C, GP, reviewed Mr Hopkins. He noted that his condition was
relatively stable, he was comfortable and did not need to be prescribed anticipatory
medicine yet. Healthcare staff continued to observe him in the following days.
40. On 9 December, Dr B reviewed Mr Hopkins. She noted that he was frail and she
had been informed that he was refusing to eat or drink. His observations were
normal. She told the clinical reviewer that she was concerned about Mr Hopkins
and she asked the Deputy Head of Healthcare to contact Dr C about his end-of-life
care. Dr C did not recall being contacted.
41. On 11 December, healthcare staff assessed Mr Hopkins and his NEWS2 score was
seven (indicating that he was significantly deteriorating and needed an emergency
assessment by a clinical team). Nurse C decided that Mr Hopkins should continue
to be monitored and assessed further the next day. Throughout the night Mr
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Hopkins was agitated and confused. Staff decided to handover this information to
day staff rather than seek medical advice during the night.
42. On 12 December at 8.00am, healthcare staff assessed Mr Hopkins. He had low
oxygen in his blood and he was not alert. His NEWS2 score was 12 (indicating that
he was at very high risk of deterioration). Healthcare staff suspected he had
pneumonia. Nurse B radioed an emergency medical code, staff called an
ambulance and paramedics quickly arrived.
43. Paramedics concluded that, due to Mr Hopkins’ condition, it would not be in his best
interests to go to hospital. They spoke to Dr B who agreed Mr Hopkins should
remain at Doncaster to receive end of life care. She had not had the training to
prescribe anticipatory medication. Around 2.00pm, Dr D, psychiatrist, prescribed
this medication, which was not needed in the end as Mr Hopkins remained pain
free.
44. The prison informed Mr Hopkins’ family about his condition and they visited him in
prison that day. Mr Hopkins died, with healthcare staff present, at 7.08pm.
Post-mortem report
45. At the time of writing, the post-mortem report was not available. However, the
Coroner confirmed Mr Hopkins’ cause of death as bilateral pneumonia. Frailty and
metastatic renal cancer also contributed to Mr Hopkins’ death.
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Findings
Clinical care
46. The clinical reviewer concluded that Mr Hopkins’ care was partially equivalent to
that which he could have expected to receive in the community. She concluded that
healthcare staff managed his long-term conditions in line with national guidance,
involved Mr Hopkins and his family in his care towards the end of his life and the
emergency response when his condition deteriorated was appropriate.
47. However, she also found that there were several occasions where healthcare staff
did not follow up on Mr Hopkins’ hospital appointments. In interview, Ms A, Head of
Healthcare, confirmed that, since Mr Hopkins’ death, several trackers had been put
in place to prevent this. Despite this, further improvements still need to be made to
ensure policies are robustly followed. We recommend that:
The Head of Healthcare should review the current Local Operational
Procedure: Outside Hospital Appointments and the live cancer tracker to seek
assurance that they are sufficiently robust, effective and fit for purpose. An
audit should then be completed within three months of the completion of the
review.
48. The clinical reviewer found that healthcare staff should have referred Mr Hopkins to
the MPCCC on 13 November 2023, when it was suspected that he had cancer. She
also noted that after Mr Hopkins’ oncology appointment on 26 June 2024, when he
was informed that he was no longer fit for cancer treatment, the wider healthcare
team was not informed of this. They only became aware of this on 20 August. This
caused a delay in care planning. We recommend that:
The Head of Healthcare and Lead GP should ensure that staff are aware of
and adhere to Local Operating Procedure for referral to MPCCC so that
referrals are completed in timely manner and staff report significant updates
with the wider team.
49. The clinical reviewer also found that healthcare staff did not appropriately identify
that Mr Hopkins was at high risk of malnutrition after losing a significant amount of
weight, and did not escalate this appropriately. This meant Mr Hopkins’ weight was
not adequately monitored towards the end of his life.
The Head of Healthcare should ensure that staff receive training in
recognising and managing prisoners at risk of malnutrition.
50. The clinical reviewer also made several other recommendations which the Head of
Healthcare will want to address.
Early release on compassionate grounds (ERCG)
51. When Mr Hopkins went to hospital on 20 April 2024, prison staff thought that he
could be approaching the end of his life, so they started to gather evidence to apply
for compassionate release to PPCS. This was good practice. However, the process
seems to have stalled once Mr Hopkins returned to prison.
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52. Staff were not clear about certain aspects of the process which led to delays and
miscommunication. Multidisciplinary discussions should have happened earlier to
determine whose responsibility it was to complete certain actions. Since Mr Hopkins
died, Mr A told us that the prison has developed a new flow chart to clarify the
process of applying for ERCG. A multidisciplinary meeting should now happen
within 10 working days of identifying that an ERCG application should be made. We
welcome this improvement to practice.
53. In a multidisciplinary meeting on 11 October, staff identified that due to Mr Hopkins’
offences he could present a risk to others and that he would be subject to stringent
licence conditions, should he be released. Staff considered that this would most
likely be a barrier in securing a hospice bed for him. However, we found that no one
was tasked with looking for accommodation for Mr Hopkins and these concerns
were not discussed with potential hospices.
54. Mr Hopkins’ family often sought updates about Mr Hopkins’ ERCG application from
healthcare staff. This was understandable as there was good communication
between the two parties. However, since the application for ERCG was a prison led
process, prison staff, such as the family liaison officer, should also have routinely
been updating Mr Hopkins’ family. We make the following recommendation:
The Director and the Head of Healthcare should review the ERCG application
process, ensuring that all staff are aware of their responsibilities and are
tenacious in obtaining the information needed.
Good Practice
55. We commend Nurse D, Nurse E, Nurse F and Healthcare Support Worker, Mr B for
providing compassionate care to Mr Hopkins in the final hours of his life and
remaining with him as he died.
Adrian Usher
Prisons and Probation Ombudsman July 2025
Inquest
The inquest hearing was held on 3 December 2025. The Coroner concluded that Mr
Hopkins died of natural causes.
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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