John Kenny

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr John Kenny,
a prisoner at HMP Preston,
on 18 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, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
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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 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 Kenny died of heart disease and kidney failure on 18 March 2023 at HMP Preston. He
was 54 years old. I offer my condolences to Mr Kenny’s family and friends.
The clinical reviewer concluded that the clinical care Mr Kenny received at Preston was of
a good standard and equivalent to that which he could have expected to receive in the
community.
We found no non-clinical issues of concern.
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 September 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 25 November 2022, Mr John Kenny was remanded to HMP Preston after being
charged with harassment and assault. At the initial healthcare screening, staff
identified Mr Kenny’s long term hypertension (high blood pressure) and continued
his medication for managing the symptoms.
2. On 3 December, wing staff found Mr Kenny confused and walking into other
prisoners’ cells. A mental health nurse assessed Mr Kenny and confirmed his
confusion but could not identify a clear cause. Mr Kenny moved to the healthcare
unit for further observation, where tests showed he had not been taking his blood
pressure medication as prescribed. Mr Kenny’s medication was removed from his
possession, and he was asked to pick it up from healthcare in future, to manage the
risk of missed doses. Further tests showed abnormal readings and Mr Kenny was
taken to hospital by an emergency ambulance for an urgent computerised
tomography (CT) scan.
3. On 8 December, the hospital renal team took a biopsy (used to obtain samples of
body tissue for closer examination) of Mr Kenny’s kidney. On 21 December, Mr
Kenny was diagnosed with stage 5 chronic kidney disease due to uncontrolled high
blood pressure.
4. The healthcare team at Preston monitored Mr Kenny closely, in between several
stays in hospital. Dialysis (a procedure to remove waste products and excess fluid
from the blood when the kidneys stop working properly) and a kidney transplant
were organised.
5. In February and March 2023, Mr Kenny attended hospital for dialysis treatment and
in the main there were no concerns documented on return to prison. On the
occasion that there was prison healthcare staff responded accordingly.
6. On 18 March, officers found Mr Kenny unresponsive in his room. They called an
ambulance and began cardiopulmonary resuscitation (CPR) before paramedics
arrived. Attempts to revive Mr Kenny were unsuccessful and his death was
pronounced at 10.07pm.
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The Investigation Process
7. We were notified of Mr Kenny’s death on 18 March 2023.
8. The investigator issued notices to staff and prisoners at HMP Preston informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
9. The investigator obtained copies of relevant extracts from Mr Kenny’s prison and
medical records.
10. NHS England commissioned a clinical reviewer to review Mr Kenny’s clinical care at
the prison.
11. We informed HM Coroner for Lancashire of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
12. The Ombudsman’s family liaison officer contacted Mr Kenny’s next of kin to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond.
13. Mr Kenny’s next of kin received a copy of the initial report. They did not raise any
concerns or issues on the factual accuracy of the report.
14. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies in the report.
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Background Information
HMP Preston
15. HMP Preston is a Category B local prison serving the courts in Lancashire and
Cumbria. It holds up to 680 adult male prisoners. Spectrum Community Health
C.I.C provides primary healthcare services 24 hours a day, seven days a week, as
well as substance misuse services. Tees Esk & Wyre Valleys NHS Foundation
Trust provides mental health services at Preston.
Previous deaths at HMP Preston
16. Mr Kenny was the seventh prisoner to die at Preston since March 2020. Of the
previous deaths, two were self-inflicted and five were from natural causes. There
are no similarities between our findings in the investigation into Mr Kenny’s death
and our investigation findings in the previous deaths.
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Key Events
17. On 25 November 2022, Mr John Kenny was charged with harassment and assault
and remanded to HMP Preston. At Mr Kenny’s initial health screening, the nurse
identified that Mr Kenny had been diagnosed with hypertension (high blood
pressure), for which he was prescribed medication. Healthcare continued Mr
Kenny’s medication, which he was allowed to keep in his cell and self-administer.
18. On 3 December at 12.57pm, wing staff found that Mr Kenny was confused and
disorientated and going into other prisoners’ cells without reason. They requested a
review by the healthcare team. A mental health nurse visited Mr Kenny to complete
a mental health assessment which confirmed his confusion but without a clear
cause. In consultation with other nursing staff and a GP working at Preston, the
nurse moved Mr Kenny to the healthcare unit for further observation. Clinical
records indicate that a care plan was created for Mr Kenny.
19. On 4 December, a nurse reviewed Mr Kenny who remained confused. Healthcare
completed blood tests, which revealed that Mr Kenny appeared to have taken only
two days’ worth of his blood pressure medication since he arrived at Preston.
Healthcare staff removed Mr Kenny’s medication from his possession, based on his
confusion and the risks surrounding missed doses. They told him to collect his
medication from the dispensing hatch in future or it would be delivered to his door.
20. Later the same day, tests found that Mr Kenny’s blood pressure was abnormal.
Nursing staff escalated concerns to the senior nurse who tested Mr Kenny’s risk of
clinical deterioration. The result showed that Mr Kenny’s risk of deterioration was
medium. An electrocardiogram (ECG – records the electrical signal from the heart
to check for different heart conditions) reading was taken, which advised urgent
medical review and an ECHO (heart ultrasound). Mr Kenny was taken by
emergency ambulance to hospital. He was kept in hospital for monitoring, while
awaiting a CT scan.
21. On 5 December, a prison multidisciplinary team (MDT) discussed Mr Kenny’s
circumstances and confirmed he was awaiting a scan in hospital. They agreed to
continue to review his care needs.
22. On 8 December, the hospital updated healthcare staff at Preston that they had
taken a kidney biopsy (a procedure that involves taking a small sample of body
tissue so it can be examined under a microscope) and were awaiting the results.
23. On 9 December, Mr Kenny was discharged from hospital and returned to Preston. A
nurse recorded that his presentation had improved, and he had settled onto the
healthcare unit. His medication was reviewed following changes made while Mr
Kenny was in hospital. (There is no record of the conclusion of the review, but we
assume it was completed and the medication adapted, based on later records.)
24. On 14 December, staff observed that Mr Kenny appeared unkempt. They made a
referral to the mental health team and the GP at Preston. A nurse completed a short
memory test, which indicated some mild cognitive impairment (mild decline in
memory). Mr Kenny’s observations were taken and did not raise any concerns. It
was noted he was awaiting follow up from the kidney department at the hospital.
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25. On 15 December 2022, Mr Kenny met with a nurse, who noted that he remained
confused and disorientated. The nurse documented that healthcare staff had
reported abnormalities in Mr Kenny’s ECG results compared to his last ECG. Staff
called the ambulance service at around 12.27am to obtain an urgent cardiology
opinion at hospital. Emergency operators informed Preston there was a seven hour
wait. At 5.13pm, the nurse spoke to the ambulance service to check the waiting
time. Mr Kenny remained confused but stated he felt well. At 8.00pm, the
ambulance arrived, and Mr Kenny was taken to hospital for further assessment of
his ongoing confusion, abnormal blood readings and abnormal ECG result.
26. On 16 December at 2.54pm, Mr Kenny was discharged from hospital and returned
to Preston. Healthcare completed his basic observations which found no concerns.
At 5.57pm, a nurse recorded there was no accompanying paperwork from the
hospital and contacted them for an update. Mr Kenny remained confused and was
moved to the healthcare unit for further observation. Nursing staff recorded that Mr
Kenny was at high risk of haemochromatosis (when iron levels in your body build up
over time) and Mr Kenny’s ferritin levels were high (ferritin plays a significant role in
the absorption, storage, and release of iron). A nurse spoke to the hospital renal
team, who noted Mr Kenny’s confusion might be due to an infection and advised
that he be taken back to hospital. Mr Kenny was returned to hospital at 6.23pm.
27. On 18 December, Mr Kenny was discharged back to Preston. Records suggest that
he settled well with no signs of confusion.
28. On 21 December, Mr Kenny had an appointment with the hospital renal team, who
shared information passed on by the hospital kidney consultant. Mr Kenny was
diagnosed with stage 5 chronic kidney disease as a result of uncontrolled high
blood pressure.
29. On 22 December, Mr Kenny was seen by a GP at Preston, who noted he was
awaiting dialysis (a procedure to remove waste products and excess fluid from the
blood when the kidneys stop working properly) and a kidney transplant. The
hospital would be in contact to organise treatments. Health records indicate that Mr
Kenny continued to experience confusion but there were signs of improvement.
30. Medical records show that pre-transplant and transplant appointments were booked
for 27 February 2023 and 2 March once prison escorts had been organised.
31. On 13 January, Mr Kenny’s high blood pressure increased again, and healthcare
staff found high potassium levels in his blood and low kidney function. Following
discussions between healthcare staff and the GP at Preston, an emergency
ambulance was called and transferred Mr Kenny to hospital.
32. On 14 January at 12.48am, Mr Kenny returned to Preston after discharging himself
from hospital. An ECG and blood tests were completed, which showed similar
results to previous tests. Mr Kenny said he felt fine. At 5.13am, staff checked Mr
Kenny’s blood pressure which remained high.
33. On 15 January, Mr Kenny attended his chronic kidney disease three monthly review
and his annual high blood pressure review. A QRISK2 (cardiovascular disease 10-
year risk score) was completed which indicated he was at high risk of having a
stroke or heart attack in the next ten years. Nursing staff provided a kidney care
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leaflet on kidney transplants and dialysis. Mr Kenny was given diet and lifestyle
advice to reduce the risk of cardiovascular disease. He said he was no longer
smoking and declined to undertake physical exercise.
34. On 20 February at 6.15pm, Mr Kenny was seen by a GP at Preston who noted his
blood pressure remained high and he was on the maximum dose of his medication.
The GP noted Mr Kenny was starting dialysis in two days and if there were any
symptoms from high blood pressure he should be transferred to hospital.
35. On 24 February, Mr Kenny started dialysis treatment. He returned to Preston later
the same day without any reported concerns.
36. Mr Kenny attended hospital for dialysis treatment on six further occasions in March.
37. On 18 March at approximately 9.10pm, Mr Kenny appeared asleep when staff went
to his cell to deliver his evening medication. When they tried to rouse him, he did
not respond. An officer tried banging his door and calling his name, but Mr Kenny
did not respond. Officers entered the cell and found Mr Kenny was not breathing. At
9.22pm, they called a code blue and commenced cardiopulmonary resuscitation
(CPR). Paramedics arrived at 9.32pm and Mr Kenny was pronounced dead at
10.07pm.
Post-mortem report
38. The post-mortem examination concluded that Mr Kenny died of coronary heart
disease (build-up of fatty material that clogs arteries). Chronic renal failure (also
known as chronic kidney disease - a long-term condition where the kidneys do not
work as well as they should) and high blood pressure were listed as contributory
factors.
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Findings
39. The clinical reviewer concluded that the clinical care Mr Kenny received at Preston
was of a good standard and equivalent to that which he could have expected to
receive in the community. She makes one recommendation unrelated to Mr Kenny’s
death which the Head of Healthcare will need to consider.
40. We found no issues with the non-clinical care provided to Mr Kenny at Preston.
When officers identified Mr Kenny’s confusion, they rightly made an urgent referral
to healthcare. Thereafter, Mr Kenny spent periods of his time in the healthcare unit
and in hospital so that his ongoing symptoms could be appropriately monitored and
investigated. We found that healthcare staff were diligent and compassionate in
their care of Mr Kenny and bring this to the attention of the Head of Healthcare.
Inquest
41. The inquest into Mr Kenny’s death concluded on the 5 July 2024. The coroner
confirmed that Mr Kenny died from natural causes.
Adrian Usher
Prisons and Probation Ombudsman September 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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