Anthony Kwan

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Independent investigation into
the death of Mr Anthony Kwan,
a prisoner at HMP Channings
Wood, on 8 July 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, 2025
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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 HM Prison and Probation Service (HMPPS) in ensuring
the standard of care received by those within service remit is appropriate then our
recommendations should be focused, evidenced and viable. This is especially the
case if there is evidence of systemic failure.
3. Mr Kwan died of metastatic pancreatic cancer (cancer of the pancreas that has
spread to other parts of his body) on 8 July 2023, at Rowcroft Hospice, while a
prisoner at HMP Channings Wood. He was 62 years old. We offer our condolences
to his family and friends.
4. The PPO family liaison officer wrote to Mr Kwan’s daughter to explain the
investigation and to ask if she had any matters she wanted us to consider. She had
no questions but asked for a copy of our report.
5. The PPO investigator investigated the non-clinical issues relating to Mr Kwan’s
care. We did not find any non-clinical issues of concern. We make no
recommendations.
6. NHS England commissioned an independent clinical reviewer, to review Mr Kwan’s
clinical care at HMP Channings Wood.
7. The clinical reviewer concluded that, in most aspects, the clinical care Mr Kwan
received at HMP Channings Wood was of a good standard and equivalent to that
which he could have expected to receive in the community. She made four
recommendations, one of which was not directly relevant to Mr Kwan’s death and is
not included in this report but which the Head of Healthcare will wish to address.
Good practice
Transfer to hospice and multidisciplinary working
8. There was good multidisciplinary working between hospital staff, the hospice staff,
prison healthcare staff and prison staff which ensured that a hospice bed was
secured promptly for Mr Kwan.
9. Mr Kwan praised the quality of family liaison he received while he was unwell.
Recommendations from clinical review
• The Head of Healthcare should ensure that there is a robust process in place for
the review of healthcare applications to ensure a timely review by the most
appropriate member of the healthcare team.
• The GP provider should review the prison GP wait times to ensure all is being done
to bring it in line with community access to GPs.
Prisons and Probation Ombudsman 1
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• The GP provider should ensure that all GPs are using the GMCs guidance on
record keeping including when using remote consultation methods.
Inquest
10. The inquest into Mr Kwan’s death concluded on 7 August 2025 and found that Mr
Kwan died of natural causes.
Adrian Usher January 2024
Prisons and Probation Ombudsman
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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