Alexander Corbett

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Independent investigation
into the death of
Mr Alexander Corbett, a
resident of Fleming House
Approved Premises
on 23 August 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, 2025
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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.
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.
Mr Alexander Corbett was found hanged at an address in the community on 23 August
2024, six days after absconding from Fleming House Approved Premises. He was 46
years old. I offer my condolences to Mr Corbett’s family and friends.
While Mr Corbett had some risk factors for suicide and self-harm, there was little to
indicate in the time before he left Fleming House that he was at heightened risk.
Nevertheless, there were missed opportunities that might have helped to prevent his
death. A GPS monitoring tag, which was required in his licence conditions, was not
ordered or fitted, which meant that probation staff and police could not identify his location
for the six days before he died.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman August 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 14
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Summary
Events
1. In February 2024, Mr Alexander Corbett was remanded in custody for offences of
stalking involving fear of violence and making threats to kill. He was later sentenced
to 16 months in prison. Mr Corbett had a history of substance misuse, primarily
alcohol, which influenced his offending behaviour, and reported a history of post-
traumatic stress disorder (PTSD) and that he had been diagnosed with anti-social
personality disorder (ASPD). Mr Corbett had attempted suicide at least once before
(in 2017), and was admitted to hospital around the time of his arrest after
expressing suicidal ideation.
2. Mr Corbett spent his time in prison at HMP Elmley. He progressed well, engaged in
activities to support other prisoners, and raised few concerns. Prison staff did not
order GPS tracking and alcohol monitoring tags ahead of his release, which Mr
Corbett’s licence required him to wear on release, and the tags were never fitted.
3. On 6 August, Mr Corbett was released to Fleming House Approved Premises (AP).
On arrival at Fleming House, Mr Corbett was inducted, and staff completed his
Support and Safety Plan (SaSP).
4. Mr Corbett complied with his curfew, participated in AP activities and had an
appointment to engage with a community personality disorder programme.
5. On 17 August, Mr Corbett left Fleming House and did not return for his curfew. AP
staff attempted to call Mr Corbett, but there was no answer. At around 9.00pm, after
further efforts to locate Mr Corbett were unsuccessful, the head of service
authorised his recall to prison.
6. On 20 August, a friend of Mr Corbett’s contacted the on-duty probation practitioner
and said that Mr Corbett had struggled at the AP and had mental health issues. Mr
Corbett’s community offender manager contacted him and attempted to obtain
address information. Mr Corbett agreed that he would report to a police station, but
did not.
7. On 23 August, Mr Corbett’s friend found him hanged and called paramedics, who
confirmed life extinct.
Findings
8. While Mr Corbett had some risk factors for suicide and self-harm, his time in prison
was largely uneventful and – until he absconded – there was little to indicate to staff
at Fleming House that he was at increased risk.
9. Important monitoring equipment was not fitted, which meant that probation staff and
police could not track Mr Corbett’s location when he did not return to Fleming
House.
10. Support for staff and residents, and contact with Mr Corbett’s family, was poorly
managed in the time following his death.
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Recommendations
• The Governor of HMP Elmley should review procedures for ordering monitoring tags
for prisoners awaiting release, identify whether the error with Mr Corbett’s licence is a
systemic issue and implement any necessary changes to mitigate this.
• The Probation Service should ensure that AP staff conduct daily alcohol tests for
residents awaiting alcohol tags to be fitted.
• The Probation Service should ensure that AP staff are aware of their responsibilities
regarding managing tagging requirements and that a clear process is in place for
staff to escalate tag fitting.
• The AP area manager should ensure that all staff at Fleming House AP are clear in
respect of the death in AP process, as set out on EQuiP.
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The Investigation Process
11. HMPPS notified us of Mr Corbett’s death on 29 August 2024.
12. The investigator issued notices to staff and residents at Fleming House informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
13. The investigator obtained copies of relevant extracts from Mr Corbett’s prison,
probation and medical records.
14. The investigator interviewed two members of staff at Fleming House on 11 October
and three members of staff via Microsoft Teams on 8, 10 and 17 October.
15. We informed HM Coroner for Kent and Medway of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
16. The Ombudsman’s office contacted Mr Corbett’s family to explain the investigation
and to ask if they had any matters, they wanted us to consider. Mr Corbett’s mother
asked why Mr Corbett was found at another address and not the approved
premises (AP). Mr Corbett’s ex-partner asked why probation services did not track
him by his GPS tag when he absconded.
17. Mr Corbett’s parents received a copy of the draft report. They did not make any
comments on the factual accuracy of the report however they provided a statement
detailing additional information regarding Mr Corbett’s personal life and requested
that we share this with the Coroner. The Ombudsman’s office shared this statement
with the Coroner on their behalf.
18. We also shared the initial report with HMPPS and agreed to amend the wording of
the recommendations 2-4 to ensure they were more effective.
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Background Information
Fleming House Approved Premises (AP)
19. Approved Premises (AP - formerly known as probation and bail hostels) mostly
accommodate offenders released from prison on licence and those directed there
by courts as a condition of bail. Their purpose is to provide a supportive and
structured environment. Residents are responsible for their own healthcare and are
expected to register with a GP.
20. Fleming House is in Maidstone, Kent and managed by the Probation Service. It has
27 single rooms (and will soon have four shared rooms). Breakfast and evening
meals are provided and there is a communal area for eating and socialising. Each
resident has a key worker to oversee their progress and wellbeing and see that they
adhere to their individual licence conditions and the premises’ rules. Staff are on
duty at Fleming House 24 hours a day.
21. Fleming House is a psychologically informed planned environment (PIPE) AP
where staff members have additional training to help them develop an increased
psychosocial understanding of individuals. PIPEs aim to support the progression of
offenders with complex needs and personality related difficulties, with a particular
focus on the local environment and recognising the importance and quality of
relationships and interactions.
Previous deaths at Fleming House
22. Mr Corbett was the second resident of Fleming House to die since August 2021.
The other resident died of natural causes, around a month before Mr Corbett. Both
deaths occurred away from the AP.
Recall
23. Recall refers to the process of returning to prison an individual who does not follow
their licence conditions. It is the responsibility of the Probation Service to initiate
recall of individuals on licensed supervision through the Public Protection Casework
Section (PPCS).
24. The recall process is set out in the Recall, Review and Re-Release of Recalled
Prisoners Policy Framework. In addition to breaching a licence condition, probation
practitioners must consider whether the recall threshold has been made, based on
an individual’s behaviour or circumstances presented whilst on licence. At the point
of initiating recall, it is the responsibility of the police to attend a known address and
arrest the individual.
Support and Safety Plan (SaSP) and Collaborative Approach to Risk and Emotion
(CARE)
25. The full SaSP aims to provide individualised information and includes an
opportunity to assess the types of risks, triggers and needs for residents, how staff
can help to prevent issues, and provide residents with a support structure including
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for supporting themselves in the event of distress. Staff are required to complete
this within the second stage of induction.
26. CARE is the AP system used to support residents at risk of suicide or self-harm.
The purpose of a CARE plan is to prevent escalation of self-harm, a suicide attempt
and reduce risk-related behaviour. After an initial assessment of the resident’s main
concerns, levels of interactions, staff actions and interventions are set according to
their perceived risk of harm.
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Key Events
Background
27. Mr Alexander Corbett had a history of violent offences, substance misuse, had
reported struggling with post-traumatic stress disorder (PTSD) and had been
diagnosed with anti-social personality disorder (ASPD). Mr Corbett had spent time
in prison and had been supervised by probation staff several times throughout his
adulthood. He had a history of self-harm and had attempted suicide by overdose in
prison in 2017, and was monitored under prison service suicide and self-harm
prevention procedures (known as ACCT) as a result.
28. Mr Corbett was prescribed propranolol (beta-blocker medication used to treat
anxiety and cardio issues) and quetiapine (medication used to treat depression,
mania symptoms, schizophrenia, and bipolar disorder).
29. On 15 February 2024, Mr Corbett was convicted of offences of stalking involving
fear of violence and making threats to kill. At the time he was under a period of
post-sentence supervision (PSS) for an offence of possession of an offensive
weapon, racially aggravated harassment, assault and actual bodily harm. Mr
Corbett was remanded in custody at HMP Elmley pending sentence.
30. Mr Corbett’s Crown Prosecution Service (CPS) papers detailed that around the time
of these offences, he was admitted to hospital after “displaying suicide intent”. Mr
Corbett’s community offender manager (COM) explained that Mr Corbett reported
hearing loud thoughts in his head especially about harming others, and having
suicidal ideation. The COM had worked with Mr Corbett in the community since
2020, and reported to have built a good rapport with him.
HMP Elmley
31. On 15 February, Mr Corbett was inducted by prison staff and referred to the mental
health in-reach team (MHIRT). The MHIRT were aware of Mr Corbett’s 2017
overdose attempt and his self-reported attempt on his life. Mr Corbett’s self-report of
PTSD, ASPD and childhood trauma were also recorded in his medical record.
32. On 22 February, Mr Corbett had a mental health assessment. The MHIRT found
that there were no signs to suggest that Mr Corbett presented a risk of harm to
himself and that he possessed no delusional or paranoid beliefs. A mental health
nurse concluded that Mr Corbett presented as having no acute mental health
symptoms or signs of enduring mental illness. Mr Corbett’s medication was
continued, and he was advised how to self-refer to the MHIRT in the future.
33. On 18 April, Mr Corbett had a substance misuse assessment and explained that
accommodation was a big concern for him. He said that he had used substances
since he was 14 years old and that he experienced PTSD from childhood trauma.
Mr Corbett said that had previously taken an overdose of his prescribed medication,
but he said he did not have any current thoughts of suicide.
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34. On 21 May, Mr Corbett was sentenced to 16 months in prison. Staff conducted a
well-being check and offered Mr Corbett an appointment with the MHIRT, which he
declined.
35. On 29 May, Mr Corbett had a keyworker session with an officer. Mr Corbett
reported no issues with his mental health and the officer noted that he appeared to
be in high spirits as he had expected to receive a longer sentence. The officer
explained to him that he would serve another four months in custody and asked Mr
Corbett for family contact information. Mr Corbett said that he had no contact with
his family.
36. On 4 June, Mr Corbett’s prison offender manager (POM) contacted the COM to
provide a handover of Mr Corbett’s time at Elmley. The COM explained that the
POM informed him that Mr Corbett had been doing well in prison, had become a
trained Listener and that there was nothing to suggest that he was at risk of suicide
or self-harm during that period. (Listeners are prisoners who are trained and
supported by the Samaritans to provide confidential, emotional support to their
peers.)
37. On 6 June, the COM submitted Mr Corbett’s AP referral. This contained the
following information about Mr Corbett’s risk and history of suicide and self-harm:
“As observed within the CPS packs, Mr Corbett has made various threats of
harm to self. He denies experiencing suicidal ideation within the custodial
environment which he described as containing. However, due to his
experiences and trauma, it is assessed that the risk to self is present. He is
encouraged to engage with the in-reach mental health services and PIPE units
in custody.”
38. The COM highlighted that Mr Corbett’s risk to self and others would likely be
increased by alcohol and drug misuse, homelessness, and difficulty in managing his
thoughts and feelings.
39. Mr Corbett’s AP referral mirrored the CPS summary of his offence. However,
information about the February 2024 hospital admission was not included. The
COM noted that, “actions prior to remand include suicidal ideation and actions” with
no further information. In interview, when asked whether the events of February
2024 were passed onto AP staff, the COM said that he did not know.
40. The COM told us that although he thought Mr Corbett might struggle at Fleming
House, as it was not in his home area, he thought that Fleming House being a PIPE
AP would provide Mr Corbett with the right support. He said that Mr Corbett
appeared positive about the move. To assist in monitoring Mr Corbett’s risk at the
AP, he requested additional measures such as additional daily sign ins (at 12.00pm
and 5.00pm) and at least weekly substance tests.
41. On 17 June, Fleming House accepted the referral.
42. Mr Corbett’s licence conditions included a curfew requirement between 9.00pm-
6.00am, additional reporting requirements at 12.00pm and 5.00pm, and a
prohibition from drinking alcohol. Mr Corbett was also required to be monitored by a
GPS tag (to monitor location retrospectively) and an alcohol monitoring tag (which
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uses sweat to determine whether alcohol has been consumed and to what level. If a
tag detects alcohol or is tampered with, an alert is sent to the Probation Service).
43. On 15 July, staff from the Apollo programme emailed Mr Corbett. (Apollo is a
community programme developed for individuals with personality disorder or with
personality disorder traits, which Mr Corbett had been assessed as suitable for in
December 2023.) The Apollo team advised Mr Corbett that he could join their late
2024 programme, after his release. Mr Corbett did not respond to their email.
44. On 16 July, Mr Corbett had a video-call with the COM, in which the COM explained
the AP placement and Mr Corbett’s licence conditions. He told us that Mr Corbett
was pleased that he had accommodation and support around him, and that he
accepted his licence conditions.
45. On 18 July, Mr Corbett was discussed at an interdepartmental risk management
meeting (IRMM). The POM attended along with healthcare and mental health staff
and social workers. In interview, she explained that Mr Corbett was discussed due
to his upcoming release, to identify any pending action. She told us that during Mr
Corbett’s time in prison, he raised no concerns and there was no evidence to
suggest that he presented a high risk of suicide and self-harm. She said that Mr
Corbett was a neurodiversity representative and that he often worked on different
wings at Elmley, supporting other prisoners.
46. Prior to Mr Corbett’s release a keyworker at Fleming House completed Mr Corbett’s
pre arrival risk assessment. (Despite requests, Fleming House did not provide a
copy of the assessment. We therefore cannot confirm if accurate suicide and self-
harm risk information was captured within this assessment.)
47. On 6 August, Mr Corbett was released from Elmley under the end of custody
supervised licence (ECSL) scheme (an early release scheme).
48. Neither of Mr Corbett’s tags were fitted following his release from prison. The
electronic monitoring service (EMS) told us that, at the point of Mr Corbett’s release,
they did not receive his licence and were therefore unaware of the tagging
requirements. The service manager for electronic monitoring operations for
HMPPS, told us that it is the responsibility of the Offender Management Unit (OMU)
team at the releasing prison to share licence paperwork prior to a prisoner being
released. She confirmed that once this is shared, a first attempt to fit the monitoring
equipment should be made by midnight on the day following release.
49. The investigator asked Elmley why an order to fit Mr Corbett’s tags had not been
sent to the EMS. The Head of Offender Management Services, advised that both
Mr Corbett’s alcohol tag and GPS tag were missed due to human error. Fleming
House were unaware that Mr Corbett’s tagging requests had not been submitted.
Fleming House AP
50. On 6 August, Mr Corbett arrived at Fleming House and was inducted by a
residential worker. The induction included an explanation of AP rules, and the
completion of a medication contract and GP consent to liaise form. Mr Corbett told
staff that he had no next of kin and handed over his medication. (Residents’
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medication is stored in a staff office and they collect and sign for it at their
prescribed medication times.) The residential worker told us that when he asked Mr
Corbett about whether he had any learning difficulties or mental health concerns, he
said, “I’ve just got mental health issues”. He said that Mr Corbett provided no further
information, and he raised no issues.
51. Later that day, staff conducted a routine urine test for drugs and alcohol. Mr Corbett
tested negative for all substances.
52. On 7 August, Mr Corbett had two appointments with staff.
• Mr Corbett attended an induction appointment with a probation officer to
discuss his licence conditions. The probation officer explained to Mr Corbett
what was expected of him and the consequences of failing to comply. Mr
Corbett reported that alcohol was his main area of concern and that, should he
relapse, it “tend(s) to spiral”. Mr Corbett also explained that he was engaged
with social services to seek contact with his son. The probation officer agreed
on several actions to support Mr Corbett, including liaising with the local
services to assess and identify any alcohol support needs. The probation
officer was not aware that the OMU had not sent tagging requests to EMS.
• Mr Corbett received his second stage induction with his keyworker. She
completed Mr Corbett’s support and safety plan (SaSP) and noted that Mr
Corbett had disclosed that his medication made him feel “quite flat” at times,
so staff would need to regularly check his mood. Mr Corbett’s SaSP detailed
that his main concerns were accommodation after his AP placement (of 12
weeks), that he had taken an overdose one year ago, and that he was not sure
if he would tell AP staff if he was struggling. Mr Corbett also told her that he
had no family contact.
53. His keyworker said in interview that she was not aware of Mr Corbett’s recent
(February 2024) stay in hospital. She said that Mr Corbett was prescribed
quetiapine, which would have helped him with managing voices and therefore, had
she known of this event, her assessment of Mr Corbett would not have changed.
54. Also on 7 August, the COM contacted the keyworker to ask if Mr Corbett’s tags had
been fitted. We do not know whether the COM received a response.
55. Over the following days, staff reported that Mr Corbett responded to all welfare
checks, attended a resident’s brunch and that no concerns were raised.
56. On 12 August, Mr Corbett had a keywork session with his keyworker. Mr Corbett
said that he had joined the local gym as he had felt bored. He also said that he was
concerned about accommodation following his AP placement and that this was at
the front of his mind. The keyworker encouraged Mr Corbett to participate in AP
activities and Mr Corbett expressed an interest in cooking for the AP brunch. She
discussed the Apollo Group and the creating future opportunities (CFO) activities
hub. Mr Corbett requested more information about Apollo and appeared open to the
activities suggested by her. She reported in interview that she had no concerns, that
Mr Corbett felt settled and that he was taking his medication.
57. On 13 August, Mr Corbett had several interactions with staff:
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• He attended a PIPE induction session with a member of staff, where staff
explained the expectations of the PIPE AP. She discussed the support
available within the Apollo Group, and Mr Corbett agreed to an appointment on
19 August.
• Mr Corbett had an appointment with the COM by video-link. The COM said
that Mr Corbett was well engaged and felt that he had settled in well to the AP.
Mr Corbett confirmed that he had registered with a GP and reported no
temptations regarding drugs or alcohol. The COM said that Mr Corbett was
concerned about being at Fleming House and ease of access to travel to
Folkestone to see his son. He explained to Mr Corbett that, although he
wished to live in the Folkestone area, due to exclusions on his licence he
would not be able to. He reassured him that a referral to a Canterbury housing
organisation had been completed.
• Mr Corbett was breathalysed for alcohol. This test gave a negative reading.
58. The investigator asked the COM whether he had considered a community mental
health referral to support Mr Corbett. He said that Mr Corbett’s mental health had
been unstable at the beginning of the year, but that he had been doing well in
prison. He said that Mr Corbett reported that he was “pretty comfortable” at Fleming
House. He said that he wanted to assess how Mr Corbett was self-reporting and
how he engaged with the Apollo Group before completing a mental health referral.
59. Over the following days, staff recorded that Mr Corbett responded to welfare checks
and complied with his medication. There were no records of staff observing any
changes in behaviour and no concerns regarding Mr Corbett being under the
influence of alcohol or drugs.
Events of 17 – 22 August
60. At 9.00am on 17 August, Mr Corbett responded to a welfare check. He signed out
of the AP at 12.02pm and returned at 12.28pm.
61. At 1.43pm, Mr Corbett signed out of Fleming House. He did not tell AP staff where
he was going.
62. By 5.00pm, Mr Corbett had not returned to the AP and missed his sign in time. A
residential worker attempted to phone Mr Corbett’s mobile, but she received no
response. She reported to the on-call manager that Mr Corbett had not returned
and that staff had been unable to reach him by phone. The on-call manager advised
AP staff to wait until Mr Corbett’s 9.00pm curfew before initiating recall.
63. At 9.07pm, the residential worker attempted to call Mr Corbett’s mobile again. After
no answer, she initiated an out of hours recall, which was agreed by the head of
service.
64. At 9.28pm, staff sent Mr Corbett’s recall notification to Kent Police and his licence
was revoked.
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65. At 11.00pm, Mr Corbett had not returned for his second curfew check. A residential
worker went to Mr Corbett’s room and found two bottles of vodka hidden behind the
bed.
66. On 19 August, his probation officer and the COM completed Mr Corbett’s recall
paperwork. This detailed that Mr Corbett had no fixed abode, was considered to
present a high risk of serious harm to others and had a history of failing to comply
with probation. The COM also documented that Mr Corbett had made previous
suicide attempts and had ASPD. He also recorded that Mr Corbett had a history of
alcohol and drug misuse.
67. On 20 August, Mr Corbett sent a text message to the COM and said that he was
“struggling with social services”. At around 3.00pm, the duty probation practitioner
received a call from a friend of Mr Corbett’s, who said that he had been staying with
her. His friend said that Mr Corbett was “a mess” and felt let down by both probation
and social services. She asked Mr Corbett’s friend for her address, however she
declined to share this information. During this call, Mr Corbett’s friend said that Mr
Corbett would like contact with the COM.
68. At 4.10pm, the COM phoned Mr Corbett’s friend to speak with Mr Corbett. He
reported that Mr Corbett’s friend answered the phone and said that she had known
him for many years, and that he had experienced mental health problems. Mr
Corbett was handed the phone and told the COM that he had struggled at Fleming
House due to “the people there” and was also frustrated at being unable to see his
son. In interview, the COM said that he attempted to obtain address information
from Mr Corbett, but Mr Corbett was worried that the police would attend and arrest
him for recall. The COM explained that he advised Mr Corbett that a warrant had
not yet been authorised, but recall was still being considered. (Although his recall
paperwork had been completed, the court had not yet issued an arrest warrant and
therefore he was unable to confirm recall with certainty.) The COM told us that Mr
Corbett said that he would prefer to surrender to a police station. He advised him
that if his recall was agreed, he would be expected to surrender immediately, which
Mr Corbett agreed to.
69. The COM told us that he discussed the approach with his manager, who advised
that Mr Corbett’s action in reaching out was positive and that once a warrant had
been received, they would ask him to attend a local police station.
70. On 21 August, the COM called Mr Corbett and informed him that his recall had
been processed. He said that Mr Corbett asked him if he would receive a 28-day
fixed term recall. He explained to Mr Corbett that although he might not remain in
custody until the end of his sentence, because he was high-risk and had absconded
from the AP, his recall would not be solely for a fixed-term. He told us that Mr
Corbett appeared to accept this, and he apologised for letting him down. The COM
reassured him. He said that Mr Corbett agreed to report to a police station by no
later than 2.00pm.
71. On 22 August, the COM contacted the police and was told that Mr Corbett had not
handed himself in. He provided the police with contact details for Mr Corbett’s
friend.
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Events of 23 August
72. The following account is based on police and ambulance records from the date of
Mr Corbett’s death.
73. Police records state that Mr Corbett had been staying at his friend’s address since
he absconded from Fleming House on 17 August. Police recorded that Mr Corbett’s
friend last saw Mr Corbett at around 4.00am on 23 August.
74. At 6.50am, Mr Corbett’s friend called for an ambulance after she found Mr Corbett
hanging from her front door.
75. At 7.05am, paramedics arrived and commenced cardiopulmonary resuscitation. At
7.36am, they pronounced life extinct.
76. Police reported that Mr Corbett’s friend said that the previous night they had
smoked crack cocaine and had a couple of cans of beer.
Events following Mr Corbett’s death
77. At 10.38am, the COM was notified of Mr Corbett’s death by a social worker.
78. At 11.34am, the COM shared the news of Mr Corbett’s death with AP staff.
Contact with Mr Corbett’s family
79. Mr Corbett’s ex-partner, his last recorded next of kin, was notified of Mr Corbett’s
death by the police. Fleming House did not have any next of kin contact details
recorded on file. We are unsure when and how Mr Corbett’s mother was notified of
his death.
80. On 2 October, the AP manager, confirmed that AP staff had not made any contact
with Mr Corbett’s ex-partner due to concerns of domestic abuse and a no-contact
licence condition between Mr Corbett and his ex-partner. The AP manager asked
the investigator for advice on approaching family liaison with her. We directed them
to the HMPPS national instructions following a death under supervision and sought
assistance from the Coroner to determine who they had liaised with regarding Mr
Corbett’s funeral.
81. On 10 October, the Coroner told us that Mr Corbett’s funeral had taken place and
that Mr Corbett’s parents did not wish to have any contact with AP staff.
82. On 11 October the AP area manager told us that in the AP manager’s absence, he
had contacted Mr Corbett’s ex-partner.
83. As a result of the no contact request from Mr Corbett’s mother, HMPPS did not
provide contributions towards Mr Corbett’s funeral costs in line with national
instructions.
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Support for residents and staff
84. Although staff were informed of Mr Corbett’s death on 23 August, a staff debrief
was not held until 29 August. Staff were signposted to relevant support services.
85. On 28 August, the AP posted notices informing other residents of Mr Corbett’s
death and held a resident meeting.
Post-mortem report
86. A post-mortem examination found that Mr Corbett died from pressure on the neck
due to hanging. Toxicology tests identified alcohol (at a level higher than the
national drink-driving limit), cocaine and benzoylecgonine (a chemical compound
produced when cocaine is metabolised in the body).
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Findings
Identifying risk of suicide and self-harm
87. Mr Corbett had several risk factors for suicide and self-harm. He had previously
attempted suicide by overdose and had been admitted to hospital in February 2024,
after disclosing suicidal intent. Mr Corbett had a history of abusing alcohol and
reported that he experienced PTSD and ASPD. He was prescribed quetiapine in
hospital in February 2024. Mr Corbett was also unemployed, reported that he had
no family contact (but was clearly anxious to regain contact with his son) and had
been homeless in the community.
88. In preparation for Mr Corbett’s release both his POM and COM liaised about Mr
Corbett’s time in custody and no concerns regarding his mental health or suicidal
ideation were raised. Mr Corbett had positively engaged in prison, fulfilling the role
of neurodiversity representative and training as a Listener, and appeared to be
motivated to progress in the community. The COM captured Mr Corbett’s history of
self-harm and risk factors such as alcohol within Mr Corbett’s AP referral. However,
details of the events of February 2024 were not documented within the self-harm
section. Nonetheless, this information was included within Mr Corbett’s AP referral
which was shared with AP staff and therefore we assess that they had sufficient
information about Mr Corbett’s risk of suicide and self-harm.
89. When he arrived at Fleming House, staff carried out a mandatory SaSP
assessment. SaSP guidance states that if there is a current risk of self-harm or
suicide, then consideration must be given to activate the self-harm prevention
approach. Mr Corbett denied any current thoughts of suicide and self-harm and staff
did not assess Mr Corbett as presenting with an increased risk. His keyworker was
aware of Mr Corbett’s historic suicide attempt (2017) however, said that she was
unaware of the events of February 2024. The keyworker reported that if she had
been aware of this, due to Mr Corbett being supported by medication, she would not
have changed her assessment of his risk of self-harm.
90. SaSP guidance states that staff should explore actions that other people can do to
help support the resident with a particular concern. Mr Corbett reported that his
medication caused him to feel “flat” and that he was not sure that he would tell staff
if he was struggling. The only support action set for Mr Corbett was for staff to
conduct regular check ins and to encourage him to attend activities. SaSP guidance
lists examples of distraction tools and activities that can support residents in
reducing their negative feelings, however there was no evidence that these had
been suggested.
91. Mr Corbett did not report needing any support with his mental health during his time
at Fleming House. He was compliant with his medication, did not display any overt
signs of deteriorating mental health and had planned to engage with the Apollo
community mental health service.
92. We assess that staff had a good understanding of Mr Corbett’s risk factors and
triggers and that it was reasonable not to start CARE procedures during the time Mr
Corbett lived at the AP. During his time at Fleming House, there was little to indicate
that he was at increased risk of suicide and self-harm or entering a period of crisis.
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Licence conditions - tagging
93. Mr Corbett’s tagging requirements formed a key part of his licence, to aid probation
staff in monitoring his risk. Mr Corbett’s alcohol misuse was recognised to
contribute towards his offending behaviour and without both of his tags (alcohol
monitoring and GPS trail monitoring), probation staff were not sufficiently equipped
to accurately monitor Mr Corbett’s risk of harm to himself or others. Had Mr
Corbett’s tags been fitted, these would have provided staff with a method of
assessing any increase in alcohol consumption and of locating Mr Corbett after he
absconded from the AP.
94. We understand that the referral to EMS for Mr Corbett’s tags was missed by staff at
Elmley when he was released and were told that this was due to human error. As a
result, the EMS provider did not receive an order to fit the tags. Mr Corbett’s release
was one of the releases under the early release scheme (a government measure to
alleviate overcrowding in prisons) but we are satisfied that staff had sufficient
notice. The Head of Offender Management Delivery at Elmley, explained that staff
had managed the early releases to the best of their ability, but that pre-release
planning and licence arrangement had been impacted. He said that following Mr
Corbett’s death, additional checks were now being carried out on all licences.
95. The AP area manager told us that where a resident is awaiting an alcohol tag, AP
staff should carry out daily alcohol tests. This was not done for Mr Corbett.
96. Although it is the responsibility of the releasing prison to instruct EMS providers to
fit tags, it is the responsibility of the Probation Service to ensure that there is
opportunity for such tags to be fitted and to chase EMS if this does not happen.
EMS guidance to HMPPS states that, “If your person on probation has not had their
tag fitted within one week of release, this is chased with EMS at the earliest
opportunity”. The COM did not contact the EMS provider until after Mr Corbett’s
death to ask if his tags had been fitted. Staff at Fleming House also did not identify
that Mr Corbett had not had tags fitted.
97. As a result, Mr Corbett was not monitored in the community in line with his licence
conditions. Had he been properly monitored, his GPS tag might have enabled
police or probation staff to locate him at an earlier stage, which might have led to a
different outcome. We make the following recommendations.
The Governor of HMP Elmley should review procedures for ordering
monitoring tags for prisoners awaiting release, identify whether the error with
Mr Corbett’s licence is a systemic issue and implement any necessary
changes to mitigate this.
The Probation Service should ensure that AP staff conduct daily alcohol tests
for residents awaiting alcohol tags to be fitted.
The Probation Service should ensure that AP staff are aware of their
responsibilities regarding managing tagging requirements and that a clear
process is in place for staff to escalate tag fitting.
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Events following Mr Corbett’s death
Family Liaison
98. The AP Manual sets out standards for family liaison following the death of a
resident. This requires the AP to appoint a family liaison officer who will offer
ongoing contact, explaining the purpose of any investigations, and including offering
assistance with funeral costs in line with HMPPS policy.
99. While Mr Corbett had not provided an updated next of kin contact at Fleming
House, his prison records listed his ex-partner as next of kin. Due to concerns of
domestic abuse and a no-contact licence condition between Mr Corbett and his ex-
partner, the AP manager was hesitant to contact next of kin. While we understand
the concerns AP staff had in contacting Mr Corbett’s ex-partner, as the most
recently recorded next of kin, reasonable steps should have been taken to offer
support and an opportunity to engage.
100. In the event where no next of kin is provided, the AP Manual says that the AP must
take reasonable steps to trace them (e.g. by consulting the Coroner). No further
attempts were taken by AP staff to identify another next of kin. By the time Mr
Corbett’s ex-partner was contacted, the investigator had been informed by the
Coroner that Mr Corbett’s funeral had taken place and that his parents had said that
they did not wish to be contacted.
Funerals
101. HMPPS policy for APs includes an obligation for the service to offer contributions
towards the cost of the funeral. The AP manager was unfamiliar with this policy and
sought advice from the PPO investigator regarding the scope of this responsibility.
At the request of Mr Corbett’s mother, AP staff made no contact and no contribution
to the cost of Mr Corbett’s funeral was made. While we appreciate that these were
difficult circumstances, an offer of a contribution to funeral expenses might have
been made through other means, such as via the Coroner.
Informing staff and residents
102. The AP Manual requires the AP to inform staff and residents and provide support
following the news of a resident’s death. Despite AP staff receiving notification of Mr
Corbett’s death on 23 August, residents were not informed for five days and a staff
debrief did not take place for six days. Although the AP Manual does not specify a
time limit in offering support and information to staff and residents, we consider this
was too long to wait. When residents are not told of a death at the earliest
opportunity, staff risk them learning through other means which might have
implications for the accuracy of information they are given or on support needs.
103. The AP area manager explained that the policy following a death of a resident was
not followed and that in both the recent deaths at Fleming House, problems with
this process have been highlighted. He said that he was not made aware of Mr
Corbett’s death until 28 August. He explained that at the time of Mr Corbett’s death,
although AP staff were informed, the notification was sent to the AP manager who
was on annual leave. The AP area manager said that staff have not received any
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training in how to manage actions following the death of a resident and that learning
has since been identified.
104. The AP area manager shared Fleming House’s Action Plan, prepared earlier in
2024, which details the following actions relating to deaths in the AP:
• Review recent deaths in Fleming House.
• Brief all staff on the process for dealing with a death in an AP.
• Look at the induction process to ensure correct and up to date next of kin
details are recorded.
• Brief AP manager on the process and policy for dealing with a death in an
approved premises.
105. In another recent death at Fleming House, we have identified similar issues in
relation to family liaison. We think this area requires particular focus and make the
following recommendation:
The AP area manager should ensure that all staff at Fleming House AP are
clear in respect of the death in AP process, as set out on EQuiP.
Inquest
106. The inquest into Mr Corbett’s death concluded on 11 April 2025, and recorded a
verdict of suicide.
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