Kenneth Kesans

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Independent investigation into the
death of Mr Kenneth Kesans, a
prisoner at HMP Usk,
on 21 December 2024
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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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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. In January 2022, Mr Kenneth Kesans was sentenced to 12 years in prison for
sexual offences. He died of pneumonia, on 21 December 2024, in hospital, while a
prisoner at HMP Usk. This was caused by an Influenza A infection (a viral infection
commonly known as flu) and idiopathic pulmonary fibrosis (a condition where the
lungs become scarred, making it difficult to breathe). He was 47 years old. We offer
our condolences to Mr Kesans’ family and friends.
4. The Ombudsman’s office wrote to Mr Kesans’ next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They wanted to
know what contributed to Mr Kesans’ death. This has been addressed in both this
report and the clinical review.
5. The PPO investigator investigated the non-clinical issues relating to Mr Kesans’
care. We did not find any non-clinical issues of concern.
6. Healthcare Inspectorate Wales commissioned an independent clinical reviewer, to
review Mr Kesans’ clinical care at Usk.
7. The clinical reviewer concluded that Mr Kesans received appropriate care and had
access to a range of health services, including excellent mental health support. He
noted that a GP promptly reviewed Mr Kesans’ condition when healthcare staff
raised concerns. However, the clinical reviewer found that healthcare staff should
have asked a GP to speak with Mr Kesans about a chest X-ray after he declined it
in November 2023. He noted that the GP could have explained the importance of
the X-ray for monitoring his condition and the potential risks of not having it. The
reviewer also noted that healthcare staff did not offer Mr Kesans a flu vaccination in
2024. We make the following recommendations regarding the clinical care Mr
Kesans received:
• The Head of Healthcare should ensure that any declined follow-up medical
appointments are reviewed and appropriately escalated to the GP.
• The Head of Healthcare should ensure that all vaccinations, including the
flu vaccine, are offered and administered in a timely manner, on an annual
basis.
8. The clinical reviewer also made one other recommendation not related to Mr
Kesans’ death which the Head of Healthcare will wish to address.
Prisons and Probation Ombudsman 1
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9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies. Their action plan is annexed to this
report.
10. Mr Kesans’ family received a copy of the draft report. They did not make any
comments.
Adrian Usher
Prisons and Probation Ombudsman September 2025
Inquest
11. The inquest into Mr Kesans’ death concluded on 8 April 2026 and returned a verdict
of natural causes. The jury concluded that Mr Kesans died from respiratory failure
which was caused by Influenza A infection and idiopathic pulmonary fibrosis.
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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