Samuel Henneberry

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Independent investigation into
the death of Mr Samuel
Henneberry, a prisoner at HMP
Whitemoor, on 10 May 2025
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. In July 2023, Mr Samuel Henneberry was sentenced to 15 years imprisonment for
manslaughter. He died of end-stage heart failure which was caused by ischaemic
heart disease (when blood poorly flows to the heart and damages it) and ischaemic
cardiomyopathy (when the heart muscle cannot pump blood well). He was 64 years
old when he died on 10 May 2025 in HMP Whitemoor. We offer our condolences to
Mr Henneberry’s family and friends.
4. The Ombudsman’s office wrote to Mr Henneberry’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
5. NHS England commissioned an independent clinical reviewer to review Mr
Henneberry’s clinical care at HMP Whitemoor. The clinical reviewer’s report is
attached as Annex 1. The clinical reviewer concluded that the clinical care Mr
Henneberry received at Whitemoor was of a good standard and equivalent to that
which he could have expected to receive in the community. She found that Mr
Henneberry’s medical records contained evidence of excellent individualised end of
life care planning. She made no recommendations.
6. The PPO investigator investigated the non-clinical issues relating to Mr
Henneberry’s care.
7. We did not find any non-clinical issues of concern. We make no recommendations.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Good Practice
9. We commend healthcare and prison staff efforts to involve Mr Henneberry’s family
in the last few months of his life by moving his son, a resident in the same prison, to
the healthcare unit so that they could be closer.
Adrian Usher December 2025
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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Inquest
The inquest hearing was held on 12 December 2025. The Coroner concluded that Mr
Henneberry died of natural causes.
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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