Prison staff at HMP Peterborough attempted to resuscitate inmate despite 'Do Not Resuscitate' order

Prison staff at HMP Peterborough performed CPR on a 65 year old prisoner, awaiting sentencing, despite a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order, an official report has found.

Geoffrey Holland, who suffered from chronic obstructive pulmonary disease, died in custody on 4 July 2024.

The Prisons and Probation Ombudsman’s report, published after an inquest concluded Holland died of natural causes, identified a serious communication failure that led to resuscitation attempts being made unnecessarily.

Holland had completed a ReSPECT form two days before his death, which included the DNACPR instruction. However, when a prisoner found him unresponsive on the morning of 4 July and alerted staff, officers—unaware of the order—initiated emergency procedures at 7.52am. CPR was performed until paramedics arrived at 8.00am, at which point a nurse presented the DNACPR order, and resuscitation efforts were halted. Paramedics confirmed Holland’s death at 8.30am.

The report criticised record-keeping failures, stating, "The lack of communication led to CPR being carried out unnecessarily, which was undignified and not in Mr Holland’s best interest." Investigators found that a newly appointed nurse failed to pass the DNACPR details to wing staff or upload them to medical records. The prison’s Head of Healthcare has since implemented new procedures to prevent similar incidents.

Holland had been remanded in custody on 16 February 2024 after being charged with possession of a bladed article in a public place. He had not been sentenced at the time of his death.

The investigation also examined whether an officer failed to carry out a welfare check when unlocking Holland’s cell. The officer was suspended during the inquiry but left the job before it was completed.

Officials attempted to contact Holland’s next of kin but were unable to trace any relatives. The prison contributed to his funeral costs in accordance with policy.

We have approached the ministry of Justice for a comment.

Hear all the latest news from across the UK on the hour, every hour, on Greatest Hits Radio on DAB, smartspeaker, at greatesthitsradio.co.uk, and on the Rayo app.