Alec Henney

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Independent investigation into
the death of Mr Alec Henney,
a prisoner at HMP Isle of Wight,
on 28 March 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, 2026
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Summary
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. Mr Alec Henney died in hospital of pneumonia caused by lung cancer on 28 March
2023, while a prisoner at HMP Isle of Wight. He was 65 years old. We offer our
condolences to Mr Henney’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Henney received at HMP
Isle of Wight was partially equivalent to that which he could have expected to
receive in the community. The clinical reviewer made three recommendations which
were not directly related to Mr Henney’s death but which the Head of Healthcare
and Governor will need to address.
5. She highlighted examples of good practice such as the regular discussions and
ongoing care provided to Mr Henney when he was admitted to the healthcare unit.
6. However, she noted that an end-of-life care plan was not in place, including for pain
management. She also noted delays in organising an X-ray for Mr Henney. While
this might not have changed the outcome for him, it delayed his access to earlier
assessment, diagnosis and treatment.
7. Isle of Wight did not appropriately keep records about the use of restraints on Mr
Henney. This prevented us being able to assess whether the use of restraints was
appropriate.
Recommendations
• The Governor should remind staff of the importance of retaining paperwork
about the use of restraints so that it is available to the PPO if required.
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The Investigation Process
8. HMPPS notified us of Mr Henney’s death on 28 March 2023.
9. Health Inspectorate Wales (HIW) commissioned an independent clinical reviewer to
review Mr Henney’s clinical care at HMP Isle of Wight.
10. The PPO investigator investigated the non-clinical issues relating to Mr Henney’s
care.
11. The PPO family liaison officer wrote to Mr Henney’s next of kin, his daughter, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She was concerned about how Mr Henney was informed of his cancer
diagnosis and the use of restraints during hospital stays.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
13. Mr Henney’s family received a copy of the draft report. They pointed out some
factual inaccuracies and/or omissions. This report has been amended accordingly.
Previous deaths at HMP Isle of Wight
14. Mr Henney was the fifteenth prisoner to die at HMP Isle of Wight since March 2021.
Of the previous deaths, 11 were from natural causes, and two were self-inflicted.
There are no similarities between the findings in our investigation into Mr Henney’s
death and the findings from our investigations into the previous deaths.
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Key Events
15. On 4 March 2022, Mr Alec Henney was convicted of sexual offences and was
sentenced to seven years imprisonment. He was sent to HMP Isle of Wight on 4
October 2022.
16. On 1 December, Mr Henney was admitted to the healthcare unit for chest pain and
breathing difficulties. A nurse assessed him and found that his observations were
within normal ranges. She made an appointment for him to see a GP the next day.
17. On 2 December, the GP noted that Mr Henney needed a chest X-ray and blood
tests. The chest X-ray was not booked.
18. On 22 December, Mr Henney said that he had ongoing chest pain. A pharmacist,
who was also an Advanced Clinical Practitioner operating at Isle of Wight,
requested a chest X-ray.
19. On 9 January 2023, a prison paramedic saw Mr Henney for ongoing chest and
abdominal pain. It was noted that the referral from the pharmacist had not been
accepted.
20. On 18 January, Mr Henney attended the hospital for the chest X-ray.
21. On 23 January, a GP at Isle of Wight phoned Mr Henney in his cell and told him that
he had lung cancer. Wing staff were not told this call was to take place.
22. On 23 February, Mr Henney agreed to be moved to the healthcare wing having
previously declined on multiple occasions.
23. On 6 March, Mr Henney was taken to hospital, restrained, for a chest infection and
possible sepsis. He was diagnosed with advanced bone metastasis. (The cancer
had spread from its original location to the bones.) He was admitted to hospital for
treatment. (The prison could not provide the paperwork related to the use of
restraints for this hospital visit, so we were unable to consider whether appropriate
decisions had been made.)
24. On 14 March, during his hospital stay, Mr Henney complained that his restraints
were too tight. The escort officer on the bedwatch checked the cuffs and advised
that they would not be removed. Mr Henney complained about the use of restraints
during his time in hospital.
25. On 15 March, having undergone emergency palliative radiotherapy, Mr Henney
returned to the healthcare unit at Isle of Wight. His cancer had spread further to his
brain, skin and spine. The hospital oncology department told Mr Henney that his
cancer could not be cured.
26. On 22 March 2023, a nurse found Mr Henney collapsed in bed. He had difficulty
breathing but was still able to talk. The nurse calculated a National Early Warning
Score (NEWS2, a tool used to assess clinical deterioration) of 10, which indicated
that he needed to be assessed urgently in hospital.
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27. Mr Henney was taken to hospital by ambulance, escorted by two prison officers and
initially without restraints. That day, the Head of Offender Management Services
decided to restrain Mr Henney with an escort chain (a long chain with a handcuff at
each end, with one attached to the prisoner and the other to an officer). Again, the
prison could not locate the documentation and the Head of Offender Management
Services could not explain why they made the decision to restrain Mr Henney.
28. The restraints were removed shortly afterwards due to Mr Henney’s poor health and
frailty.
29. A few hours later, Mr Henney was discharged from hospital and returned to Isle of
Wight.
30. On 24 March, Mr Henney was returned to hospital by ambulance because of low
oxygen saturation levels. He was struggling to breathe and had a NEWS2 score of
six (indicating medium clinical risk). Mr Henney was escorted by two officers and
not restrained on this occasion.
31. On 27 March, the hospital said that Mr Henney had a prognosis of two days. His
daughter was informed, and a visit was arranged for her to see Mr Henney the
following day.
32. At 8.25am on 28 March, Mr Henney was pronounced dead. The family liaison
officer called his daughter to tell her that he had died.
Post-mortem report
33. The post-mortem report concluded that Mr Henney died of pneumonia caused by
metastatic adenocarcinoma of the lung (lung cancer which has spread to other
parts of the body) and chronic obstructive pulmonary disease (COPD, a lung
disease). Severe fatty change of the liver was also listed as a contributory factor.
Inquest
34. At an inquest held on 23 October 2025, the Coroner concluded that Mr Henney died
of natural causes.
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Non-clinical findings
Restraints, security and escorts
35. Isle of Wight did not keep proper records of their restraints decisions about Mr
Henney. The paperwork about Mr Henney’s hospital stay from 6 to 15 March (when
he complained about the restraints that were used) was missing. In the absence of
records, we were unable to assess whether the use of restraints was appropriate.
36. When Mr Henney was taken to hospital on 23 March, he was restrained with an
escort chain. Mr Henney’s cancer was advanced, and it had spread by this point. In
the prisoner escort record, Mr Henney was documented as being extremely weak.
We have seen no evidence to justify the decision to restrain him in the days before
he died. While we accept that restraints were removed shorty after Mr Henney’s
health deteriorated, we were unable to ascertain why Mr Henney was restrained
because of the lack of records. We therefore make the following recommendation:
The Governor should remind staff of the importance of retaining paperwork
about the use of restraints so that it is available to the PPO if required.
Governor and Head of Healthcare to note
Communication about Mr Henney’s diagnosis
37. Mr Henney was informed of his cancer diagnosis by phone at 7.00pm on 23
January. It is unclear whether he was alone or with his cellmate at the time.
Healthcare staff had not told prison staff that this call was to take place and prison
staff were only told about it by another prisoner the following day. Prison staff saw
Mr Henney that day to offer support.
38. The GP operating at Isle of Wight told us that the healthcare team told Mr Henney
his cancer diagnosis by telephone because they could not accommodate a face-to-
face appointment with him until after he had been sent for an urgent cancer
appointment. This was considered a better option.
39. We recognise that there is no policy in place about how best to inform prisoners of
their diagnoses. However, we consider that the way Mr Henney was told of such a
serious diagnosis - by telephone in his cell, in the evening and without wing staff
being alerted of the call so they could support him afterwards - did not take into
account his potential wellbeing and safety following the news.
Adrian Usher
Prisons and Probation Ombudsman January 2024
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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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