A jailed child abuser died of cancer just days on from his diagnosis after prison staff "missed opportunities" to detect it.
HMP Frankland inmate Steven Lord was serving a 21-year sentence in the infamous County Durham prison for carrying out sickening abuse decades earlier.
He reportedly raped a young girl in the back of his van, and sexually abused two others.
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A court heard he showed "no remorse" for the abuse.
Now a new report has revealed he died last October 5, less than a week after his cancer was diagnosed.
The 53-year-old, who had a string of health issues including heart disease, had been suffering with chest pain since August. By September, "he still had pain when breathing" and visited the prison GP.
However a watchdog has now criticised the care he received prior to his death, with doctors failing to follow guidelines by urgently referring Lord for cancer investigations.
Ultimately, after spending the next few weeks in and out of hospital, he was diagnosed with lung cancer on September 30.
"He was seen in healthcare by a MacMillan nurse to discuss palliative care," states a Prisons and Probation Ombudsman report.
"Mr Lord agreed that if his condition deteriorated, he did not want to be resuscitated and signed an order to that effect."
Yet just days later he died in hospital of pneumonia, as a result of the cancer.
And in the new report, Assistant Ombudsman Karen Johnson said: "The clinical reviewer concluded that the clinical care that Mr Lord received at Frankland was not of the required standard and was not equivalent to that which he could have expected to receive in the community.
"Healthcare staff missed opportunities to identify Mr Lord’s cancer and escalate his care."
Just this week, ChronicleLive revealed the Ombudsman had again criticised the Category A prison's health provider following the death of another inmate from cancer.
Arsonist Stephen Dawes faced a string of delays during his cancer treatment, with the watchdog ruling that the standard of care he received was "variable".
The Ombudsman criticised G4S, which operated the prison's healthcare during Dawes' treatment.
Since then, another private firm - Spectrum Community Health - has taken over the contract.
Addressing the latest report, a spokesperson for Spectrum said: "As with all independent Death in Custody reviews Spectrum is working closely with our employees to ensure all recommendations in the report have been fully engaged with and implemented."
The prison earned the nickname 'Monster Mansion' as it houses some of Britain's most notorious criminals including terrorists and murderers like Ian Huntley.