Alaa Ghanem

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Independent investigation into
the death of Mr Alaa Ghanem,
on 14 January 2022,
following his release
from HMP Exeter
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
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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. From 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the prisoner’s release.
3. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
4. Mr Alaa Ghanem (also known as Ali Ganme) died of drug misuse on 14 January
2022, two days after he was released on bail from HMP Exeter. He was 34 years
old. We offer our condolences to those who knew him.
5. Mr Ghanem had a long history of substance misuse and he engaged with
Substance Misuse Services (SMS) while in prison. However, he told SMS staff that
he had no intention to stop using drugs. SMS staff referred him to drug support
services in the community, but he did not attend. On entry to Exeter, Mr Ghanem
told staff that he used heroin and asked to be prescribed methadone (both opioids).
Staff did not discuss naloxone (a fast-acting medication that can reverse the effects
of opioid overdose) with him at that time. Mr Ghanem was released on bail without
much notice. Integrated Substance Misuse Services at HMP Exeter attempted to engage
with him to discuss harm reduction, but he did not want to engage. He was released
without naloxone. Both heroin and methadone were found in his body after he died.
Recommendations
• The Head of Healthcare at HMP Exeter should ensure that prisoners who are
assessed as being at risk of opioid overdose are provided with naloxone training at
the earliest opportunity and given a naloxone kit when they leave prison.
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The Investigation Process
6. The PPO investigator obtained copies of relevant extracts from Mr Ghanem’s prison
records.
7. We informed HM Coroner for Plymouth, Torbay and South Devon of the
investigation. The Coroner gave us the results of the post-mortem examination.
We have sent him a copy of this report.
8. Mr Ghanem had no nominated next of kin. The investigator contacted Mr
Ghanem’s local Islamic Centre which was believed to have had some contact with
Mr Ghanem’s family, but they did not respond.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS asked for a change to paragraph 5, regarding attempts to discuss harm
reduction with Mr Ghanem before he left prison. A clarification has been made.
Their action plan is annexed to this final report.
2 Prisons and Probation Ombudsman
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Background Information
HMP Exeter
10. HMP Exeter holds up to 561 adult men and young offenders, and serves the courts
of Devon, Cornwall and Somerset. GP and primary care health services are
delivered by Practice Plus Group, formerly known as Care UK. Devon Partnership
NHS Trust provides mental health services and EDP Drug and Alcohol Services
provides substance misuse services.
HM Inspectorate of Prisons (HMIP)
11. The most recent inspection of HMP Exeter was a scrutiny visit (a shorter inspection
designed for the COVID-19 pandemic) in March 2021. Inspectors reported that
there was a high turnover of staff at all levels and one-third of frontline staff had
been in post for less than a year. They found that more progress was needed to
create a safer, more decent and secure prison. Inspectors noted that relationships
between prisoners and staff were not good enough.
12. Inspectors found that there had been little progress in addressing long-standing
deficiencies in the care of prisoners at risk of suicide and self-harm. Levels of self-
harm had increased during the pandemic and were very high.
13. Inspectors reported that a new post of discharge coordinator had been implemented
during the pandemic. This role included ensuring that patients had all necessary
information before release and were given medication to take home and naloxone if
required. More robust community arrangements were made where necessary for
those with mental health and substance misuse needs.
Independent Monitoring Board (IMB)
14. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 31 December 2021, the IMB said
that a combination of staff shortages, maintenance issues and COVID-19 had
affected the preparation of prisoners for release from prison. They also noted some
progress in the prevention of illegal drugs being brought into the prison.
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Key Events
15. On 29 October 2021, Mr Alaa Ghanem (also known as Ali Ganme) was remanded
in prison custody, charged with harassment, and sent to HMP Exeter.
16. When he arrived in prison, staff started suicide and self-harm prevention
procedures (known as ACCT) for Mr Ghanem as he had a history of self-harm.
Shortly afterwards, Mr Ghanem harmed himself because he was angry that he
could not have cocaine. He told staff that he smoked crack cocaine daily and also
made and sold it. Staff supported Mr Ghanem using ACCT procedures for most of
the time he was in prison.
17. Mr Ghanem was first seen by a member of the Substance Misuse Services (SMS)
on his second day at Exeter and then regularly after that, including on the day of his
release. He told SMS staff that he had no intention to stop taking drugs and that he
would use crack cocaine until he died.
18. On 12 November, SMS staff made an initial referral to a community substance
abuse programme, Harbour. (A full referral was made on 13 January 2022, the day
after Mr Ghanem’s release. Mr Ghanem did not attend Harbour before his death.)
19. Mr Ghanem expected his case to be determined at court on 6 December 2021.
However, on that day, the court adjourned his case until April 2022, and Mr
Ghanem’s solicitor made an application for bail. On 12 January, Mr Ghanem was
released on bail, with the requirement that he should comply with a curfew (he was
electronically tagged) and report weekly to a police station.
20. Mr Ghanem was due to report to the police station on 14 January. He left his
accommodation at around 10.00am and returned shortly before his 7.00pm curfew.
The person providing his accommodation said that Mr Ghanem was unsteady on
his feet and quickly fell asleep in the living room. She left the room and did not
return until around 9.30pm, when she found Mr Ghanem unresponsive. She called
for an ambulance and paramedics arrived within a few minutes. They started
cardiopulmonary resuscitation (CPR) but were unsuccessful in reviving Mr Ghanem
and he was declared dead at 9.59pm.
Pre-release planning
21. Mr Ghanem was released from prison on bail. There was no Probation Service
involvement in his case. SMS staff at Exeter made appropriate referrals for
continuity of substance misuse support in the community following his release. The
SMS at Exeter said that Mr Ghanem did not take naloxone on his release. His SMS
worker tried to speak with him about harm reduction on the day of his release but
Mr Ghanem, who was given very little notice of his release, was preoccupied with
leaving the prison and did not want to engage. Post-mortem report
22. The post-mortem report concluded that Mr Ghanem died of drug misuse.
Toxicology results showed recent use of heroin, methadone (a heroin substitute),
diazepam (used to treat anxiety but also misused recreationally) and sertraline (an
antidepressant, and the only medication listed that Mr Ghanem was prescribed).
He also had traces of cocaine in his body.
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Findings
Substance misuse
23. Mr Ghanem had used drugs over a long period of time. He engaged with SMS staff
at Exeter but told them that he intended to continue to take drugs when he was
released. Although Mr Ghanem’s substance misuse was focussed on cocaine, he
told staff on arrival at Exeter that he had used heroin and asked them to prescribe
methadone. However, tests showed no trace of opioids (the active substance in
heroin and methadone) in his body. Naloxone training was not discussed with him
at that time, and when he was released without much notice on 12 January, he was
focussed on leaving the prison and did not want to engage with his SMS worker.
24. In the circumstances of his death, it is unlikely that possession of naloxone would
have made any difference to the outcome for Mr Ghanem. However, had the other
person in the house returned earlier to the room that Mr Ghanem was in, it might
have done. Conversations about naloxone should take place with prisoners at the
time that their substance misuse is initially discussed, especially if they say that
they use opioids. This will normally be soon after they enter prison and this would
have been the appropriate moment to discuss it with Mr Ghanem. Prisoners are
often transferred or released suddenly with very little notice, as was the case with
Mr Ghanem. We recommend:
The Head of Healthcare at HMP Exeter should ensure that prisoners who are
assessed as being at risk of opioid overdose are provided with naloxone
training at the earliest opportunity and given a naloxone kit when they leave
prison.
Kimberley Bingham
Acting Prisons and Probation Ombudsman October 2022
Inquest
The inquest, held on 6 October 2023, concluded that Mr Ghanem’s death was drug
related.
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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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