Ryan Kenny

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Independent investigation into
the death of Mr Ryan Kenny, on
9 April 2025 following his
release from HMP Altcourse
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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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. 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. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
4. Mr Ryan Kenny died on 9 April 2025, following his release from HMP Altcourse
earlier that day. The cause of his death could not be ascertained. He was 30 years
old. We offer our condolences to those who knew him.
5. Mr Kenny had a history of substance use. Although he still had issues with alcohol
when he entered prison and was actively withdrawing, he declined to engage with
the substance misuse team.
6. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Kenny. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Kenny’s death on 10 April 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Kenny’s prison
and probation records.
9. We informed HM Coroner for Liverpool of the investigation. He gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
10. The Ombudsman’s office contacted Mr Kenny’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. She asked if Mr
Kenny was released homeless, was he housed in the exclusion zone set in his
licence conditions, what attempts the prison had made to contact Mr Kenny’s family
to inform them of his death, and they asked for a copy of our report. These
concerns have been addressed in our report and in separate correspondence.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
12. Mr Kenny’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Altcourse
13. HMP Altcourse is a category B prison which holds convicted and remanded male
prisoners. It is managed by Sodexo.
Probation Service
14. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
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Key Events
Background
15. On 13 March 2025, Mr Ryan Kenny was charged with breach of a criminal
behaviour order and was sentenced to 10 weeks in prison. He was sent to HMP
Altcourse. Mr Kenny was due to be released on 9 April.
16. Mr Kenny had diagnoses of schizophrenia, personality disorder, ADHD and suffered
with anxiety and depression. He was prescribed quetiapine (antipsychotic
medication) to support his mental health. He was referred to the mental health team
and a mental health assessment was completed on 19 March.
Pre-release planning
17. On 14 March, a member of staff from the substance misuse team saw Mr Kenny.
Mr Kenny said that he did not want to engage with their service. He said that he did
not feel his alcohol use was a problem, he had stopped using illicit drugs and felt he
did not need the support. Mr Kenny had no further contact with the substance
misuse team. He was not offered naloxone (medication that reverses the effects of
an opioid overdose) training.
18. On 25 March, a psychiatrist started a psychiatric assessment. Mr Kenny said he
had stopped using crack cocaine and heroin and last used synthetic cannabinoids
in prison four months ago. Mr Kenny told him he wanted a prescription of pregabalin
(medication for epilepsy and anxiety but often misused for its sedative effects) to
help his mental health, but the psychiatrist said it was not appropriate or safe. Mr
Kenny did not like this response, and he left the assessment early.
19. On 4 April, a probation officer was allocated as Mr Kenny’s Community Offender
Manager (COM). She referred him for Approved Premises accommodation (AP -
accommodation which provides additional supervision to those who present a high
or very high risk to the public on release) in preparation for his release. Merseyside
AP approved the application later that day.
20. The COM also referred Mr Kenny for CRS accommodation (Commissioned
Rehabilitative Service) and completed a DTR (Duty to Refer) to the local council, to
ensure he had support with finding permanent accommodation on release in case
he was not given an AP place.
21. On 8 April, a nurse went to see Mr Kenny, but he refused to engage. She gave him
a discharge letter for his community GP, but he said he did not want it. She also
informed him that she had referred him to the community mental health team at
Clock View Hospital, so Mr Kenny could receive ongoing support for his mental
health. The nurse left the discharge letter and the community mental health team
details in his cell.
22. Mr Kenny had additional licence conditions relating to substance and alcohol use,
mental health and had an exclusion zone.
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Post-release management
23. On 9 April, Mr Kenny was released on licence from Altcourse. He was not offered a
naloxone kit.
24. Mr Kenny attended his initial probation appointment with the COM. He said that he
was being set up to fail because the AP was too close to his exclusion zone and
that he would breach it. He said he wanted to go to his job centre appointment to
get some money so he could smoke crack cocaine and drink alcohol before he went
to the AP. She told him she would order him a taxi to take him to the AP, but he
declined the offer and took a bus ticket instead. She told Mr Kenny he had to arrive
at the AP by 4.00pm so that his alcohol tag could be fitted.
25. Mr Kenny did not attend the AP by 4.00pm. Staff decided to recall Mr Kenny to
prison because his whereabouts were unknown and they were concerned about the
risk he might pose to staff and residents at the AP, if he arrived intoxicated or under
the influence of illicit substances.
Circumstances of Mr Kenny’s death
26. At 5.53pm on 9 April, the police found Mr Kenny unresponsive on the side of a
street close to the AP. They started CPR and called an ambulance. The paramedics
arrived at 6.00pm and administered two rounds of naloxone and adrenalin. At
6.24pm, the paramedics pronounced life extinct.
27. On 10 April, the police called the AP to inform them of Mr Kenny’s death.
Post-mortem report
28. The post-mortem report concluded that the cause of Mr Kenny’s death could not be
ascertained. Toxicology results showed Mr Kenny had consumed alcohol at some
point prior to his death.
29. A member of the public told the police they thought Mr Kenny had taken synthetic
cannabinoids prior to his death, but there was no evidence of recent use found in
the toxicology results. However, the toxicologist noted they were unable to test for
the more common strands of synthetic cannabinoids, therefore its presence could
not be excluded completely.
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Findings
Substance misuse
30. Mr Kenny had a long history of alcohol and substance use, and he had previously
engaged with the community drug and alcohol services.
31. On arrival at Altcourse, Mr Kenny said he was not using drugs or alcohol and
refused support from the prison substance misuse service. As a result, they did not
refer Mr Kenny to the community drug and alcohol services.
32. The substance misuse manager at Altcourse told the investigator that because Mr
Kenny chose to not engage with their service and was not on any opiate substitute
therapy medication, he was not offered naloxone on release. They said that at the
time of Mr Kenny’s death, naloxone was only offered to prisoners who actively
engaged with the service.
33. However, the healthcare substance misuse lead told the investigator that all
prisoners with a history of substance use should be offered naloxone regardless of
their engagement. Mr Kenny was not offered naloxone on release, and it was not
documented within his pre-release screening. She said that training on the local
naloxone policy was now offered to healthcare staff and would be reviewed until
managers were satisfied that naloxone was consistently being offered to prisoners
with a substance use history regardless of either they have engaged with the
substance misuse service and is documented correctly on the system.
34. Although Mr Kenny was abstinent from alcohol and illicit substances at the time of
his release, he had a history of alcohol and substance use, which was linked to his
offending behaviour. As a result, the COM included additional licence conditions
relating to alcohol and substance use. She told the investigator that because Mr
Kenny was only in prison for a short sentence her priority was to find him
accommodation and therefore, she had not referred him to CGL (Change, Grow,
Live – the community drug and alcohol service). However, Mr Kenny would have
been regularly drug tested at the AP, and his alcohol consumption would have been
monitored through his alcohol tag. We therefore make no recommendation.
Mental health
35. Mr Kenny informed staff that he wanted support with his anxiety and wanted
medication to help him with this. He was appropriately referred to the mental health
services and assessed accordingly. We are satisfied that the mental health team at
Altcourse supported Mr Kenny with his mental health issues and referred him to the
community mental health services ahead of his release and ensured that he had
mental health support in place in the community.
Accommodation
36. We consider that the COM appropriately prepared for Mr Kenny’s release. She
liaised with external support agencies, provided up-to-date information before his
release, arranged appropriate accommodation at an AP and advised Mr Kenny of
his release date and licence conditions. She promptly completed accommodation
referrals to the local authorities and homelessness charities to ensure he was
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supported with finding both temporary and long-term accommodation on release.
The accommodation sourced for him was outside his exclusion zone.
37. We make no recommendations.
Inquest
38. At the inquest held on 3 October 2025, the coroner concluded that cause of Mr
Kenny’s death was unascertained.
Adrian Usher
Prisons and Probation Ombudsman January 2026
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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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