Reginald Northrop

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Reginald Northrop,
a prisoner at HMP The Verne,
on 28 June 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
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 concerned.
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. On 1 August 2017, Mr Reginald Northrop was sentenced to 12 years in prison for
sex offences. He died from progressive multiple sclerosis on 28 June 2024, while a
prisoner at HMP The Verne. He was 80 years old. We offer our condolences to Mr
Northrop’s family and friends.
4. The Ombudsman’s office wrote to Mr Northrop’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
had no questions but asked for a copy of our report.
5. Mr Northrop’s family received a copy of the draft report. They did not make any
comments.
6. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
7. The PPO investigator investigated the non-clinical issues relating to Mr Northrop’s
care. We did not find any non-clinical issues of concern.
8. NHS England commissioned an independent clinical reviewer to review Mr
Northrop’s clinical care at HMP The Verne.
9. The clinical reviewer concluded that the clinical care Mr Northrop received at The
Verne was of a varying standard and was partially equivalent to that which he could
have expected to receive in the community. She found that healthcare engaged well
with Mr Northrop’s wife about his end-of-life care, but improvements were needed in
starting timely end-of-life care. The clinical reviewer made a number of
recommendations which the Head of Healthcare will want to address. We repeat
two of them in this report as they were related to Mr Northrop’s death:
The Head of Healthcare should ensure that all patients on the palliative care
pathway have an advanced care plan in place in accordance with the NICE
guideline [NG142] for ‘end of life care for adults: service delivery’ (2019) and
the NHSE ‘universal principles for advanced care planning’ (2022). This care
plan should include ceiling of care decisions and treatment escalation plans
and be shared with social care staff who may care for patients out of hours.
The Head of Healthcare should ensure that there is a clear process in place
for patients discharged from hospital to HMP The Verne on an end-of-life care
pathway. This process will ensure that any recommendations from the
hospital are initiated quickly, and that treatment escalation plans and ceiling
of care decisions are translated into care plans in accordance with the NHSE
framework for ‘dying well in custody charter’ (2024).
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
10. At an inquest held on 15 September 2025, the Coroner concluded that Mr Northrop
died of natural causes.
Adrian Usher June 2025
Prisons and Probation Ombudsman
2 Prisons and Probation Ombudsman
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