Alan Haldane

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Alan Haldane,
a prisoner at HMP Littlehey, on
16 May 2023.
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, 2025
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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.
If my office is to best assist HM 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.
Mr Alan Haldane died of hemoperitoneum (internal bleeding between the abdominal wall
and the internal abdominal organs) on 16 May 2023, at HMP Littlehey. He was 69 years
old. I offer my condolences to Mr Haldane’s family and friends.
The clinical reviewer concluded that the healthcare Mr Haldane received at HMP Littlehey
was of a good standard and equivalent to that he could have expected to receive in the
community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman November 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 6
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Summary
Events
1. On 19 December 2015, Mr Alan Haldane was charged with sexual assault and sent
to HMP Lewes. On 7 April 2016, he was sentenced to six and half years in prison.
2. Mr Haldane had pre-existing medical conditions, which included COPD and
hypertension.
3. On 18 August, Mr Haldane was transferred to Littlehey.
4. On 13 September 2017, Mr Haldane was sentenced to a further 15 years in prison
for rape. He remained at Littlehey.
5. On 11 May, a GP at Littlehey saw Mr Haldane after he had been experiencing dull,
achy, abdominal pain for the past few days. The GP examined him and gave him
another appointment the next day, but Mr Haldane did not attend.
6. On 14 May, Mr Haldane told prison staff that he was feeling discomfort when he
urinated. Prison staff called the healthcare unit but they got no response. Mr
Haldane said that he was happy to wait to go to the healthcare drop-in session, the
next morning.
7. At around 9.30am on 16 May, a prisoner told prison staff that Mr Haldane was in
pain. An officer attended his cell and asked Mr Haldane where his pain was, and he
pointed to his lower stomach. Mr Haldane was drifting in and out of consciousness.
The officer called a medical emergency code and healthcare staff responded. Mr
Haldane was grey and had no pulse so healthcare staff started cardiopulmonary
resuscitation (CPR).
8. Two ambulance paramedics and one air ambulance crew arrived. The paramedics
took over Mr Haldane’s care but, at 10:10am, they confirmed that Mr Haldane had
died.
Findings
9. The clinical reviewer concluded that the care Mr Haldane received at Littlehey was
of a good standard and equivalent to what he could have expected to receive in the
community.
10. The clinical reviewer was satisfied that Mr Haldane had received a good level of
care for the management of his long-term conditions.
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The Investigation Process
11. HMPPS notified us of Mr Haldane’s death on 16 May 2023. The investigator issued
notices to staff and prisoners at HMP Littlehey informing them of the investigation
and asking anyone with relevant information to contact her. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Haldane’s prison and
medical records.
13. NHS England commissioned a clinical reviewer to review Mr Haldane’s clinical care
at the prison.
14. We informed HM Coroner for Cambridgeshire of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
15. The Ombudsman’s family liaison officer contacted Mr Haldane’s son to explain the
investigation and to ask if he had any matters he wanted us to consider. He did not
respond to our letter.
16. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Littlehey
17. HMP Littlehey is a category C male prison. It holds up to 1,220 male prisoners
convicted of sexual offences. Northamptonshire Healthcare NHS Foundation Trust
provides healthcare services at the prison.
HM Inspectorate of Prisons
18. The most recent inspection of HMP Littlehey was in August 2019. Inspectors
reported that there was a wide range of good and responsive primary care clinics
and services. Systems to identify and support patients with long-term conditions
and complex health needs were impressive, this included a range of specialist
clinics and a well-developed response to patients with social care needs.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to January 2022, the IMB reported
that the health services continued to work cooperatively with the prisoners, who
benefitted from seamless healthcare services. Throughout the year, the healthcare
team worked well with the prison staff to respond rapidly to keep prisoners as safe
as possible.
Previous deaths at HMP Littlehey
20. Mr Haldane was the 45th prisoner to die at Littlehey since May 2020. Of the
previous deaths, 41 were natural causes, two were self-inflicted and one was a
drug-related death.
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Key Events
21. On 19 December 2015, Mr Alan Haldane was remanded to HMP Lewes charged
with sexual assault of a child. On 7 April 2016, he was sentenced to six and half
years in prison. He remained at Lewes and transferred to Littlehey on the 8
September 2017. On 13 September, Mr Haldane was sentenced to a further 15
years in prison for rape. He remained at Littlehey.
22. Mr Haldane had several pre-existing medical conditions, which included a right
inguinal hernia repair, emphysema (damage in the lungs that causes
breathlessness), hypertension (high blood pressure) and chronic obstructive
pulmonary disease (COPD- a long-term, incapacitating respiratory disease).
Healthcare staff prescribed appropriate medications to manage his conditions.
23. Following Mr Haldane’s arrival at Littlehey, healthcare staff managed his long-term
conditions using the long-term conditions pathway and he had reviews for his
COPD and hypertension regularly.
24. Mr Haldane was diagnosed with an iliac aneurysm (a bulging and weakness in the
wall of the iliac artery in the pelvis) in 2019, and regularly attended Cambridge
University Hospital for assessments with the vascular surgeons’ team. The decision
was made by the vascular team that it would not be possible to attempt to repair the
aneurysm due to the risk of respiratory failure. The surgeons explained this to Mr
Haldane and agreed to treat the aneurysm conservatively and, if the aneurysm
ruptured, they would take a palliative approach (relieving symptoms without dealing
with the cause of the condition).
25. On 10 May 2023, Mr Haldane told an officer that he was having pain in his lower
region. A female member of healthcare staff went to see him, but Mr Haldane said
that he was happy to wait until the next day to see a male member of healthcare
staff.
26. On 11 May, a GP at Littlehey completed a medical review with Mr Haldane. During
this review, Mr Haldane said that he had been having dull, achy abdominal pain, all
over his abdomen and back for the last few days. The GP examined Mr Haldane
and prescribed him with co-codamol and made another appointment for Mr Haldane
to see another GP at the prison, the next day. There is no record that the GP
discussed Mr Haldane’s iliac artery aneurysm with him during the appointment.
27. The next day, for reasons unknown, Mr Haldane did not attend his appointment with
the other GP.
28. On 15 May, a nurse saw Mr Haldane, and he had a urine test. The result showed
no abnormalities.
Events of 16 May 2023
29. At about 9.30am on 16 May, a prisoner told prison staff that Mr Haldane was in
pain. An officer attended Mr Haldane’s cell and asked him where his pain was and
he pointed to his lower stomach. Mr Haldane was drifting in and out of
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consciousness. She called a code blue (indicating a prisoner is unconscious or is
having breathing difficulties).
30. Several members of healthcare staff responded. Mr Haldane was grey and had no
signs of a pulse or breathing. The healthcare team took it in turns to perform CPR.
They used a defibrillator, but no shock was advised.
31. The ambulance crew and air ambulance paramedics attended and took over Mr
Haldane’s care. Mr Haldane was given two rounds of adrenaline, but he still had no
heart rhythm. After 30 minutes of CPR with no improvements, at 10.10am, the
paramedics confirmed that Mr Haldane had died.
Contact with Mr Haldane’s Family
32. The prison appointed a Custodial Manager (CM) as the Family Liaison Officer
(FLO).
33. The FLO telephoned Mr Haldane’s son and informed him of Mr Haldane’s death
and offered his condolences and support.
34. Mr Haldane’s funeral took place on 19 June. The prison contributed to the costs of
the funeral in line with national policy.
Support for prisoners and staff
35. After Mr Haldane’s death, the Head of Functions debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team offered support, as well as line
manager support, PAM assist (Employee Assistance Programme) and TRIM
(Trauma Risk Management) support.
36. The prison posted notices informing other prisoners of Mr Haldane’s death and
offered support.
Post-mortem report
37. The post-mortem report gave Mr Haldane’s cause of death as haemoperitoneum
(internal bleeding between the abdominal wall and the internal abdominal organs).
He also had a ruptured common iliac artery aneurysm and high blood pressure. The
post-mortem found that the ruptured iliac artery aneurysm had resulted in a large
volume of blood gathering in the abdominal cavity and pelvis. These findings were
sufficient to account for Mr Haldane’s sudden death.
38. At the inquest held on the 13 December 2023 the coroner concluded Mr Haldane
died of natural causes.
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Findings
Clinical care
39. The clinical reviewer concluded that the clinical care Mr Haldane received at HMP
Littlehey was of a good standard and was equivalent to what he could have
expected to receive in the community.
40. The clinical reviewer noted that the GP in the prison did not apparently discuss Mr
Haldane’s iliac artery aneurysm with him at the appointment on 11 May. The
reviewer concluded that this was appropriate given the vascular surgery team’s plan
to manage the aneurysm palliatively should it rupture.
Good Practice
41. Mr Haldane received a good standard of care for the management of his long-term
conditions and appropriate care plans were in place to manage these.
42. The healthcare team also delivered the emergency response effectively.
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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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