Anthony Kennedy

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Anthony
Kennedy, a prisoner at HMP
Altcourse, on 12 February 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, detained
individuals in immigration centres, and people recently released from prison.
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.
Mr Anthony Kennedy died in hospital from a combination of health conditions and mixed
drug toxicity on 12 February 2023, while a prisoner at HMP Altcourse. He was 44 years
old. I offer my condolences to Mr Kennedy’s family and friends.
The clinical reviewer concluded that the clinical care that Mr Kennedy received at
Altcourse was of a good standard and was equivalent to that which he could have
expected to receive in the community. She made no recommendations.
We make no recommendations but draw the Director’s attention to the protocols around
recording COVID-19 testing and how the prison follows up drug related deaths.
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 February 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
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Summary
Events
1. On 3 February 2023, Mr Anthony Kennedy was remanded to HMP Altcourse,
charged with burglary. On arrival he tested positive for several illicit drugs, and
healthcare staff prescribed him methadone to reduce his withdrawal symptoms.
2. Staff opened an ACCT (a process to manage and support people in prison at risk of
suicide and self-harm) when he arrived in prison because Mr Kennedy said that he
would self-harm. However, Mr Kennedy refused to engage with the ACCT or with
healthcare staff trying to assess his health.
3. On 7 February, Mr Kennedy began to engage with staff, and participated in the
review of his substance misuse treatment. He asked for his methadone dose to be
increased, but when the substance misuse service (SMS) worker tried to discuss
this with him on 10 February, he was not prepared to engage with them.
4. The following day, Mr Kennedy felt unwell and thought he might have COVID-19.
When staff unlocked Mr Kennedy’s cell on the morning of 12 February, he was still
unwell and did not want to collect his medication, including his methadone. Later
that morning, officers returned to his cell with a COVID-19 test for Mr Kennedy, but
he was unconscious.
5. Resuscitation efforts from prison, healthcare and ambulance staff, succeeded in
partially reviving Mr Kennedy and he was taken to hospital, but he died shortly after
arriving there.
Findings
6. The clinical reviewer found that the clinical care that Mr Kennedy received at
Altcourse was of a good standard and was equivalent to that which he could have
expected to receive in the community.
7. Mr Kennedy was mostly non-compliant with substance misuse and healthcare staff,
but they did attempt to engage with him while he was at Altcourse. When he
became ill on 11 and 12 February, prison staff encouraged Mr Kennedy to take a
COVID-19 test. However, the recording of COVID-19 tests by staff on the wing
appears to have been informal, and not to have been co-ordinated with healthcare
staff who were unaware of any COVID-19 testing of Mr Kennedy.
8. It is not known how Mr Kennedy obtained the medication which was found in his
body post-mortem, and which was not prescribed to him. Altcourse has a drug
strategy which is reviewed monthly but in light of Mr Kennedy’s death, the Director
may wish to consider whether this sufficiently addresses the issue of prisoners
taking medication which has not been prescribed to them.
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The Investigation Process
9. HMPPS notified us of Mr Kennedy’s death on 12 February 2023.
10. The investigator issued notices to staff and prisoners at HMP Altcourse informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
11. The investigator obtained copies of the relevant extracts from Mr Kennedy’s
medical and prison records.
12. NHS England commissioned an independent clinical reviewer to review Mr
Kennedy’s clinical care at Altcourse.
13. We informed HM Coroner for Liverpool and the Wirral of the investigation. He
provided us with the post-mortem report. We have sent the Coroner a copy of this
report.
14. The Ombudsman’s family liaison officer contacted Mr Kennedy’s sister to explain
the investigation and to ask if she had any matters she wanted us to consider. She
asked questions about Mr Kennedy’s behaviour and care at Altcourse which are
covered by the clinical review and this report.
15. The initial report was shared with Mr Kennedy’s sister. She did not make any
comments.
16. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies.
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Background Information
HMP Altcourse
17. HMP Altcourse is a category B local prison, receiving sentenced and remanded
adult male prisoners as well as young offenders, from the Cheshire and Merseyside
courts. The prison can accommodate up to 1,164 men and has a very high turnover
of prisoners. About half the population are on remand or serving very short
sentences. At the time of Mr Kennedy’s death, the prison was managed by G4S. It
has been managed by Sodexo since 1 June 2023.
HM Inspectorate of Prisons
18. The most recent inspection of Altcourse was in November 2021, when prison life
was still severely affected by COVID-19. Although inspectors had concerns about
prisoners’ safety, they said that relationships between staff and prisoners were
good and the prison was calm and well-ordered.
19. Inspectors were concerned about a lack of robustness in tackling the drugs problem
in the prison. They said that after the break enforced by COVID-19, the recently
resumed random drugs testing was returning a high positive rate of 19%. The
inspectors were concerned about the administering of some medications including
controlled drugs and called for a more rigorous approach. However, they said the
flow of intelligence within the prison was good.
Independent Monitoring Board
20. 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 June 2022, the IMB reported that
Altcourse remained a safe prison and this was evidenced by the continuing
reduction in levels of self-harm and violence.
21. The IMB also commented on good staff – prisoner relationships and on some of the
positive initiatives that had contributed to this. They said that an expansion of in-cell
medication storage (with an increase in in-cell safes) gave prisoners greater
ownership of their health.
Previous deaths at HMP Altcourse
22. Mr Kennedy was the 25th prisoner to die at Altcourse since February 2020. Of the
previous deaths, eighteen were from natural causes and six were self-inflicted.
There are no similarities between the previous deaths and that of Mr Kennedy. This
was the first confirmed drug related death that the PPO has investigated at
Altcourse since we began investigating fatal incidents in 2004, although there was a
death that may have been related to Psychoactive Substances in 2015.
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Key Events
23. On 3 February 2023, Mr Kennedy was remanded to HMP Altcourse, charged with
burglary. He had a history of self-harm and substance misuse. Mr Kennedy was
clinically obese and had asthma but had no other known significant physical health
issues. Mr Kennedy refused to engage with healthcare staff, and they were unable
to carry out clinical observations on him. Mr Kennedy said he was going to self-
harm, so staff started suicide and self-harm support procedures, known as ACCT.
Staff set observations at two an hour and two conversations a day.
24. Mr Kennedy tested positive for several illicit drugs, including cannabinoids, cocaine,
and opiates. Healthcare staff prescribed Mr Kennedy methadone to lessen his
withdrawal symptoms.
25. The next day, Mr Kennedy was still hostile to healthcare staff, and they were unable
to carry out an initial mental health assessment. He also refused to engage with the
ACCT process, but staff maintained regular observations on him.
26. On 5 February, healthcare staff attempted a second health screening (which
involves exploring any health problems in detail to ensure prisoners receive the
necessary treatment and support), but once again Mr Kennedy refused to
cooperate. Although he complained of a stomach ache, Mr Kennedy would not let
nurses take his clinical observations, but he asked to see a doctor.
27. On 6 February, Mr Kennedy still did not want to engage with nurses and declined a
mental health assessment. He was seen by a doctor on the same day who found
nothing significant, but prescribed medication to alleviate Mr Kennedy’s stomach
ache.
28. On 7 February, following his refusal to engage with the mental health team, and
because there were no concerns regarding his mental health arising out of his
ACCT, they removed him from their caseload.
29. The next day, Mr Kennedy changed his mind about speaking to the mental health
team and asked to see them. He also engaged with the five-day review of his
substance misuse treatment. He asked for his methadone to be increased from the
40 mg dose that he had been receiving since his arrival at Altcourse.
30. At his ACCT review that day, Mr Kennedy was described as “upbeat and chatty
throughout”. He said that he was much happier following a wing move, and as there
were no other issues of concern, staff decided to stop the twice hourly checks but
continue with the conversations.
31. Mr Kennedy did not raise any concerns with staff over the next few days. CCTV
footage indicated that Mr Kennedy’s cell door was often open, with plenty of
prisoners coming and going, although nothing that raised any suspicions. An officer
wrote in his ACCT document on 10 February that he had spent most of the morning
talking to Mr Kennedy and had offered to write to his bank for him to cancel his
bank card. In the afternoon, Mr Kennedy spoke to a member of staff about helping
him with an issue he had about his food. He did not raise any other issues.
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32. That day, a substance misuse service (SMS) worker visited Mr Kennedy, but he
refused to engage with him. The SMS worker arranged another meeting for the
following week.
33. On the morning of 11 February, an officer wrote in Mr Kennedy’s ACCT document
that he might have COVID-19 and so he had stayed in his cell. (It is not recorded
why they thought that Mr Kennedy might have COVID-19). A further entry later that
day said that Mr Kennedy told an officer that he had taken a COVID-19 test, and the
officer said that he should have another test the next day. (There is no record of the
result of this test or who gave it to him although it is assumed that it was negative
since he was advised to re-test the next day.)
34. When Mr Kennedy was unlocked by a prison officer on the morning of 12 February,
he said that he was too tired to collect his medication and felt really ill. The officer
said that Mr Kennedy should do a COVID-19 test later. Shortly before midday, that
officer asked another officer to visit Mr Kennedy to see if he now wanted to collect
his medication. When the officer arrived outside Mr Kennedy’s cell, a prisoner
(who’s name was not recorded) told them that he was not well but was refusing to
take a COVID-19 test. Therefore, the officer decided to get a COVID-19 test kit
before returning to Mr Kennedy with another officer who she asked to assist in
getting him to take the test.
35. When the officers went into the cell, they found Mr Kennedy unresponsive, and they
could not feel a pulse. They radioed a code blue (a medical emergency radio code
used when a prisoner is unconscious or having breathing difficulties that alerts
healthcare staff and prompts the control room to call an ambulance), and officers
began attempts to resuscitate Mr Kennedy. Healthcare staff took over when they
arrived shortly afterwards, and they continued to work on the scene with the
ambulance crew when they arrived at 12.12pm.
36. Following the efforts of those attending Mr Kennedy, at around 12.37pm his heart
began pumping blood again. Paramedics took Mr Kennedy to the ambulance at
around 12.50pm. However, in the ambulance, his heart stopped again. The
paramedics continued resuscitation attempts in the ambulance on the way to
hospital, where it arrived at 1.10pm. Mr Kennedy’s heart re-started briefly again at
1.15pm but unfortunately this was not sustained, and he was declared dead at
1.26pm.
Contact with Mr Kennedy’s family
37. Normally, following a death, prison staff would visit a prisoner’s next of kin to inform
them. However, while Mr Kennedy was still being resuscitated by clinical staff at the
prison, a prisoner told his family what was happening, and they contacted the prison
for further information. Initially, Altcourse could not discuss this over the phone due
to confidentiality issues and the need to verify their identification, as well as to
establish the facts. Once this was done, rather than delay informing the family any
further, the family liaison officer (FLO) telephoned the next of kin to let them know
what had happened.
38. The FLO maintained contact with the next of kin over the following days and offered
a contribution to funeral expenses in line with HMPPS policy.
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Support for prisoners and staff
39. After Mr Kennedy’s death, the Head of Security held a debrief for the staff involved
and they were offered support.
40. The prison also posted notices informing prisoners and staff of Mr Kennedy’s death
and offering support.
Cause of death
41. The post-mortem report concluded that Mr Kennedy died from the combined effects
of several factors. These were, morbid obesity (meaning he was severely
overweight with a risk to his health), cardiomegaly (an enlargement of the heart
which can cause a number of symptoms such as abnormal heart rhythms),
pneumonia, pulmonary emphysema (damage to the air sacs in the lungs), and
mixed drug toxicity. The pathologist noted that as well as detecting the drugs that
had been prescribed to Mr Kennedy, there were also two prescription drugs which
had not been prescribed to him. These were codeine (a painkiller) and quetiapine
(an antipsychotic). Although none of the prescription drugs were at a significantly
elevated level, the pathologist noted that that these drugs may have had a
depressant effect on Mr Kennedy’s breathing and central nervous system. There
were also unknown consequences of this unauthorised combination of medication.
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Findings
Clinical care
42. The clinical reviewer said that the clinical care that Mr Kennedy received was of a
good standard and was equivalent to that which he could have expected to receive
in the wider community. Mr Kennedy was mostly non-compliant with substance
misuse and healthcare staff, but they continued to attempt to engage with him while
he was at Altcourse.
Monitoring of Mr Kennedy
43. Mr Kennedy’s family asked the PPO what staff checks were made on him as they
were concerned he had not been looked after appropriately. Mr Kennedy was
supported and monitored by staff under ACCT procedures for the whole time he
was at Altcourse. Staff also tried to assist Mr Kennedy in other ways as previously
detailed, such as by offering to write to his bank. Although Mr Kennedy often did not
wish to engage with staff, they continued to monitor him throughout his time at the
prison. We are satisfied that he was offered an appropriate level of care by prison
and healthcare staff.
Director to note
Mr Kennedy’s misuse of prescription medications
44. The misuse of prescription drugs in prison is well documented, and the risks of
prisoners diverting prescriptions to sell or pass on to other prisoners include the
effects on the good order of a prison as well the possibilities of harmful side effects,
unknown interactions with other medication and substances, and overdoses.
45. Sodexo took over the management of Altcourse on 1 June 2023, nearly four months
after the death of Mr Kennedy. They issued an updated substance misuse strategy
in July which is reviewed every month. In the strategy document, they note that the
secretion and diversion of medication remains a concern at the prison and that
prisoners may sell or be bullied by other prisoners into passing on their prescription
medication. The strategy highlights the importance of intelligence in tackling
prisoners trading prescription medication.
46. Staff at Altcourse told us that when medication is issued by nurses, prison officers
are in attendance to ensure medication is not diverted or given to the incorrect
prisoner. All prisoners collecting medication must provide their ID card before
medication is issued. Anyone caught diverting medication has their medication
reviewed by a doctor and an intelligence report of the incident is made by prison
staff.
47. It is not known how Mr Kennedy obtained medication that had not been prescribed
to him. Mr Kennedy’s clinical records show that on previous sentences healthcare
staff had suspected him of trying to obtain drugs or diverting his medication.
However, staff had no similar concerns during this short time at Altcourse. Staff told
the investigator that although periodically there had been problems with trading of
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drugs on the wing Mr Kennedy was on, there was no known recent activity relating
to this.
48. Once the involvement of drug toxicity in Mr Kennedy’s death had been determined,
the investigator asked Altcourse if there had been a subsequent investigation at the
prison. There was no evidence that this had occurred. In addition, the last
inspection by HMIP showed a very concerning rate of positive drug tests and
concerns about how drugs were administered. However, this is the first death at
Altcourse that has been confirmed as due to drugs since the PPO started
investigating deaths in prisons in 2004.
49. Given Altcourse is now under new management, with a monthly review of the drug
strategy we make no recommendation. However, the Director may wish to consider
whether the substance misuse strategy adequately addresses prisoners taking
drugs which have not been prescribed to them, to ensure there is an opportunity to
learn from Mr Kennedy’s death.
COVID-19 testing
50. Staff recorded in Mr Kennedy’s ACCT that he had taken a COVID-19 test on 11
February. The next day, staff went to his cell with another test for him to take when
they found him unresponsive. The Head of Healthcare told us that healthcare staff
were not informed that prison staff had tested him for COVID-19 as they should
have been.
51. There was no outbreak of COVID-19 at the time Mr Kennedy was at Altcourse, and
the restrictions around COVID-19 had been lifted many months previously. We also
recognise that COVID-19 was not implicated in his death. However, given the
seriousness of earlier outbreaks, including five deaths at Altcourse, the Director
may want to consider the learning from this incident.
Inquest
52. The inquest into Mr Kennedy’s death concluded on 15 September 2025. This found
that Mr Kennedy died due to taking a combination of prescription and non-
prescription drugs, which, along with his pre-existing health conditions, contributed
to his cardiac arrest.
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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