George Haldenby

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Independent investigation into
the death of Mr George
Haldenby, a prisoner at HMP
The Verne, on 29 January 2022
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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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. On 28 September 2017, Mr George Haldenby was convicted of arson and
sentenced to eight years in prison. He died from congestive cardiac failure and
hypertensive and ischaemic heart disease on 22 January 2022, while a prisoner at
HMP The Verne. He was 56 years old. We offer our condolences to Mr Haldenby’s
family and friends.
4. The Ombudsman’s office contacted Mr Haldenby’s daughter to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked us about his prison and clinical care. We have answered her questions in the
clinical review and in separate correspondence.
5. NHS England commissioned an independent clinical reviewer to review Mr
Haldenby’s clinical care at The Verne.
6. The clinical reviewer concluded that the clinical care Mr Haldenby received at The
Verne was not equivalent to what he could have expected to receive in the
community. Mr Haldenby had a diagnosis of ischaemic heart disease, heart disease
and atrial fibrillation. There was a delay in referring him to a cardiologist and
creating a long-term condition care plan. Mr Haldenby did not see a cardiologist
before he died. Mr Haldenby had poor compliance with his prescribed medication,
which contributed to the deterioration of his cardiac conditions. We make the
following recommendations:
• The Head of Healthcare should ensure that prisoners with life limiting
conditions have an advanced care plan in accordance with guidelines.
This should be regularly reviewed and specific to the prisoner’s needs.
• The Head of Healthcare should ensure the process for referrals to
secondary care is robust and regularly monitored.
• The Head of Healthcare should ensure that the missed medication
policy provides clear guidance to staff about action that must be taken
when critical medication is missed.
7. The clinical reviewer also made recommendations relating to other aspects of Mr
Haldenby’s care, which the Head of Healthcare will need to address.
The investigator investigated the non-clinical issues relating to Mr Haldenby’s care.
We found no non-clinical issues of concern.
8. We shared the initial report with Mr Haldenby’s family. The solicitor representing his
daughter wrote to us and asked a question that does not impact on the factual
Prisons and Probation Ombudsman 1
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accuracy of this report. We have provided clarification by way of separate
correspondence to the solicitor.
9. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Inquest
10. At the inquest, which took place between 20 April and 13 May 2026, the Coroner
concluded that Mr Haldenby died of natural causes. The Coroner commented that
the effects of an act of self-harm in May 2020, in circumstances where Mr Haldenby
did not adequate medication for his heart disease and exertion on the day of his
death hastened Mr Haldenby’s death.
Adrian Usher
Prisons and Probation Ombudsman April 2025
2 Prisons and Probation Ombudsman
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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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