Key Points
- Peter Honnor, aged 55, died of myocarditis at HMP Wandsworth in south London on 27 June 2024, after his cellmate found him unresponsive around 4.18am.
- Prison staff failed to immediately call a code blue emergency, causing delays in response; the night patrol officer could not enter the cell without a key.
- CPR performed by healthcare and prison staff was inadequate, with paramedics noting insufficient chest compression depth, excessive speed, incorrect defibrillator pad placement, and no oxygen administration.
- A Prisons and Probation Ombudsman (PPO) clinical reviewer ruled that Mr Honnor did not receive the community-standard care expected, particularly in investigating low blood sodium levels and prior symptoms.
- Mr Honnor, remanded on 6 May 2024 for threatening someone with a blade, had a history of heart attacks, heart failure, chest pain, dizzy spells, and three falls (two with head injuries) during his seven weeks in custody.
- Earlier incidents included admission to healthcare on 23 May for blood pressure monitoring, a request for GP on 18 June (waitlisted to 25 June), and a code blue on 22 June after blackout, with no CT scan or doctor discussion.
- A nurse admitted to the PPO that healthcare staff lacked effective leadership during resuscitation and did not follow guidelines.
- The PPO instructed the prison governor and head of healthcare to investigate the night’s events, paramedic concerns, and develop staff improvement plans.
- Coroner confirmed natural causes death at inquest on 12 September 2025.
- Oxleas NHS Foundation Trust, providing healthcare at the prison, has been contacted for comment but no response detailed in reports.
A 55-year-old prisoner at HMP Wandsworth died in June 2024 after staff failed to perform proper CPR following cardiac arrest, as revealed in a Prisons and Probation Ombudsman (PPO) report published this week. Peter Honnor succumbed to myocarditis despite multiple prior health warnings during his brief custody, with paramedics criticising resuscitation efforts upon arrival. The incident underscores ongoing safety concerns at the notorious south London facility.
- Key Points
- Who Was Peter Honnor and Why Was He in Custody?
- What Happened on the Night of His Death?
- How Did Staff Fail in Performing CPR?
- What Other Care Shortcomings Were Identified?
- What Has the Prisons and Probation Ombudsman Recommended?
- What Is the Official Cause of Death and Inquest Outcome?
- Why Is HMP Wandsworth Under Scrutiny Again?
- What Broader Issues Plague HMP Wandsworth?
- Could Better Care Have Saved Peter Honnor?
Who Was Peter Honnor and Why Was He in Custody?
Peter Honnor, 55, was remanded in custody to HMP Wandsworth on 6 May 2024, charged with threatening a person with a blade or sharply pointed article in a public place, as reported by Charlotte Lillywhite of Evening Standard. He had a documented history of heart attacks and heart failure, which became evident soon after arrival through repeated healthcare interactions.
As detailed in the PPO investigation covered by Evening Standard’s Charlotte Lillywhite, Mr Honnor experienced chest pain, dizzy spells, and at least three falls – two resulting in head injuries – during his short stay. Healthcare staff saw him multiple times, admitting him to the prison healthcare unit on 23 May where blood pressure was monitored twice daily.
On 18 June, Mr Honnor requested a GP appointment feeling he might pass out, added to the waiting list for 25 June, though no record confirms he saw one, and a nurse noted him as “well” that day.
What Happened on the Night of His Death?
Around 4.18am on 27 June 2024, Mr Honnor’s cellmate alerted a night patrol officer that he was not breathing, according to the PPO report highlighted by Charlotte Lillywhite in Evening Standard. The officer called for help but did not immediately radio a code blue emergency, stating he lacked a mandatory cell key to enter.
Other officers and healthcare staff eventually arrived, opened the cell, and began CPR, but paramedics took over at 5.19am and pronounced him dead. Paramedics raised concerns about the resuscitation quality performed prior to their arrival.
In a summary by the London News Today podcast, paramedics specifically noted chest compressions at inadequate depth and excessive speed, defibrillator pads attached incorrectly, and no oxygen treatment.
How Did Staff Fail in Performing CPR?
Paramedics informed the PPO that prison and healthcare staff delivered CPR below standards, with compressions too shallow and fast, wrong defibrillator placement, and absence of oxygen, as per Charlotte Lillywhite’s Evening Standard article. A nurse told the ombudsman,
“healthcare staff did not offer effective leadership during the resuscitation and their approach did not comply with guidelines”.
The PPO’s clinical reviewer emphasised that while Mr Honnor’s heart had stopped and resuscitation success was unlikely, CPR must always follow guidelines precisely.
This echoes broader PPO findings on resuscitation lapses, though specific to Mr Honnor’s case as reported across sources.
What Other Care Shortcomings Were Identified?
The clinical reviewer found healthcare staff ceased investigating Mr Honnor’s low blood sodium levels after medication changes, without probing other causes or progressing heart failure, recommending a structured case review instead.
On 22 June, after Mr Honnor blacked out and fell against a cell wall prompting a code blue, staff assessed him as normal by arrival but took no further action: no doctor discussion, no CT scan consideration.
What Has the Prisons and Probation Ombudsman Recommended?
The PPO directed HMP Wandsworth’s governor and head of healthcare to probe the night’s events and paramedic concerns, identify learning points, and create a staff improvement action plan, as stated in the report via Evening Standard.
London News Today reported the ombudsman highlighting failures in investigating low sodium and inadequate care amid Mr Honnor’s heart history.
Oxleas NHS Foundation Trust, responsible for prison healthcare, was contacted for comment by Evening Standard but no statement provided in available coverage.
What Is the Official Cause of Death and Inquest Outcome?
A coroner confirmed Mr Honnor died of natural causes – myocarditis – following an inquest concluded on 12 September 2025, per Charlotte Lillywhite’s Evening Standard reporting.
Despite natural causes, the PPO stressed substandard care deviated from community expectations.
Why Is HMP Wandsworth Under Scrutiny Again?
HMP Wandsworth faces repeated criticism for deaths and care failures. The PPO still investigates cases like Peter Honnor alongside Warren Arter, as noted in Putney News coverage of prison conditions.
A BBC report detailed inmate Rajwinder Singh’s 2023 suicide amid poor ACCT management, falsified checks, and missed opportunities at the prison.
Patryk Gladysz’s August 2025 inquest found care failures likely contributed to his self-inflicted death, per INQUEST.
What Broader Issues Plague HMP Wandsworth?
HM Inspectorate of Prisons reported 10 self-inflicted deaths since the last inspection, with high self-harm rates and 40% of cell bells unanswered within five minutes.
Putney News highlighted David Wise’s 2021 heat-related death from faulty heating, adding to cases like Daniel Beckford (2023 overdose) and others with procedural lapses.
A Doughty Street update noted jury findings of neglect in Rajwinder Singh’s death.
Staffing shortages hampered operations from June 2023 to May 2024, per Independent Monitoring Board via BBC.
Could Better Care Have Saved Peter Honnor?
The PPO clinical reviewer concluded Mr Honnor “did not receive the care at HMP Wandsworth that he could have expected to receive in the community,” though resuscitation success remained improbable post-arrest.
Failures spanned delayed response, poor CPR, uninvestigated sodium issues, and ignored fall risks, collectively falling short.
