Ian Henderson

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Independent investigation into
the death of Mr Ian Henderson,
a prisoner at HMP Isle of Wight,
on 27 March 2021
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. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr Ian Henderson died of multiple organ failure on 27 March 2021, while a prisoner
at HMP Isle of Wight. He was 56 years old. I offer my condolences to Mr
Henderson’s family and friends.
4. The clinical reviewer concluded that the care Mr Henderson received at HMP Isle of
Wight was equivalent to that which he could have expected to receive in the
community. He made no recommendations.
5. We did not find any non-clinical issues of concern. We make no recommendations.
Investigation Process
6. NHS England commissioned an independent clinical reviewer to review Mr
Henderson’s clinical care at HMP Isle of Wight.
7. The PPO investigator has investigated non-clinical issues, including Mr
Henderson’s location, the security arrangements for his hospital escorts, liaison with
his family and whether compassionate release was considered.
8. Mr Henderson’s next of kin, his partner, received a copy of the initial report. She
did not raise any further issues, or comment on the factual accuracy of the report.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Isle of Wight
10. Mr Henderson was the sixteenth prisoner to die at Isle of Wight since March 2019.
Of the previous deaths, ten were from natural causes and five were self-inflicted.
There have been five further deaths since Mr Henderson’s death, all from natural
causes.
11. There are no similarities between our findings in the investigation of Mr
Henderson’s death and the previous deaths.
Prisons and Probation Ombudsman 1
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Key Events
12. On 11 June 2020, Mr Ian Henderson was sentenced to nine years in prison for
historic sexual offences. He was sent to HMP Bristol.
12. Mr Henderson had been previously diagnosed with a hernia and sciatica. He also
had a history of alcohol misuse, particularly in the six months prior to his trial. He
was referred to the prison’s alcohol misuse clinic.
13. On 17 September, Mr Henderson transferred to HMP Isle of Wight.
14. At his initial health screen, a nurse noted Mr Henderson’s pre-existing conditions
and his history of alcohol misuse. She referred him to the prison’s substance
misuse team for continuity of his alcohol misuse treatment.
15. On 19 January 2021, a nurse saw Mr Henderson after he complained of being short
of breath and having had a persistent cough for the previous two weeks. He told her
that he had also coughed up blood speckled sputum. She took his observations and
they were all within a normal range. Mr Henderson had follow up reviews on 23
January and 1 February. His observations were normal, his sputum was clear, and
he had no new symptoms.
16. On 8 February, Mr Henderson was the subject of a Code Blue emergency after
telling prison staff that he was suffering from a shortness of breath, chest pain and
an increased heart rate. A prison GP saw Mr Henderson and noted that his oxygen
saturation level fluctuated between 75% and 90% (a normal oxygen saturation level
is 95% to 100%) and that his heart rate was erratic. He was taken to St Mary’s
Hospital, Newport, by emergency ambulance.
17. In hospital, Mr Henderson was diagnosed with pneumonia with effusion (a build-up
of fluid between the lung and chest wall) affecting his right lung. He was also
diagnosed with a pulmonary embolism (a blockage in an artery of the lung). Tests
were carried out and a chest drain was inserted to drain the fluid from his chest. He
was admitted as an inpatient and discharged back to Isle of Wight on 13 February.
Mr Henderson was prescribed medication to prevent further episodes of pulmonary
embolisms and care plans were created to manage his condition. Prison healthcare
staff reviewed him daily.
18. A GP carried out a follow up review on 16 February. He noted Mr Henderson
continued to suffer from a shortness of breath and a persistent cough. Mr
Henderson also told the GP that he had seen evidence of blood in his urine. The
GP considered he was suffering from a frank haematuria (less than one millilitre of
blood evident in urine). He made a two week wait referral to the urology department
at St Mary’s hospital.
19. The GP carried out a further review on 23 February. Mr Henderson told him that he
had been suffering from upper abdominal and lower chest pain. The GP requested
blood tests and the results showed that Mr Henderson had developed jaundice.
2 Prisons and Probation Ombudsman
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20. On 25 February, Mr Henderson attended St Mary’s Hospital for his two week wait
referral. The GP reviewed the results the following day. Mr Henderson was
diagnosed with thickening and inflammation of the gallbladder and a blockage
caused by small cysts. He had an urgent ultrasound scan which revealed nothing of
note. Mr Henderson was referred for an Oesophagus-Gastro-Duodenoscopy (OGD
- a thin flexible camera inserted into the throat).
21. The GP saw Mr Henderson on 1 March. He noted he appeared more jaundiced
than before and that there was evidence of a build-up of fluid in his lower right leg.
He also noted that despite adjustments to his prescribed medications, there was still
evidence of abdominal pain and swelling.
22. The OGD was carried out at St Mary’s Hospital on 8 February. The results showed
that Mr Henderson had developed multiple throat tumours each measuring
approximately ten centimetres. In addition, a single eight-centimetre tumour was
found in his small intestine. Biopsies were taken and Mr Henderson was admitted to
hospital as an inpatient to await the results. The results showed that Mr Henderson
had developed oesophageal (throat), bile duct and duodenal cancer (cancer in the
small intestine) which had also spread to his lymph nodes. Hospital staff considered
that palliative care was the only treatment option open to him.
23. On 23 March, Mr Henderson was transferred to Southampton General Hospital to
undergo a surgical procedure to identify the extent of the damage in his gallbladder,
bile ducts and pancreas. While in hospital, hospital staff signed a Do Not Attempt
Cardiopulmonary Resuscitation (DNACPR) order on Mr Henderson’s behalf, which
meant that in the event his heart or breathing stopped, he would not be
resuscitated. Mr Henderson returned to St Mary’s Hospital on 26 March.
24. Mr Henderson’s condition continued to deteriorate in hospital and at 1.15pm on 27
March, Mr Henderson died. His death was confirmed by a hospital doctor at
1.27pm.
Post-mortem report
25. A post-mortem concluded that Mr Henderson died of multiple organ failure caused
by carcinoma of the oesophagus. Mr Henderson also had severe liver failure which
did not cause but contributed to his death.
Lisa Burrell March 2022
Assistant Ombudsman
Inquest
At the inquest, held on 19 August 2025, the Coroner concluded that Mr Henderson died
from natural causes.
Prisons and Probation Ombudsman 3
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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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