Amanda Fitzpatrick

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Independent investigation into the
death of Ms Amanda Fitzpatrick, a
resident of Edith Rigby House
Approved Premises,
on 19 March 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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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. Ms Amanda Fitzpatrick died from aspiration of gastric content (fluids or solid
particles go into the windpipe or lungs) caused by dihydrocodeine (a strong opioid
painkiller) overdose on 19 March 2025, while a resident of Edith Rigby House
Approved Premises (AP). She was 39 years old. We offer our condolences to those
who knew her.
4. Ms Fitzpatrick had a history of substance (crack cocaine, heroin, cocaine, cannabis,
pregabalin) and alcohol use. She worked with Inclusion at HMP New Hall to
address her substance use, and remained drug free following her recall to prison in
December 2023. Following her release to Edith Rigby House, there is no evidence
that Ms Fitzpatrick used illicit drugs or consumed alcohol in the time before her
death.
5. On 18 March, Ms Fitzpatrick left Edith Rigby House and did not return for her
curfew. AP staff tried to contact her by telephone, but did not consider contacting
the electronic tagging system providers to establish Ms Fitzpatrick’s location.
Prisons and Probation Ombudsman 1
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The Investigation Process
6. HMPPS notified us of Ms Fitzpatrick’s death on 26 March 2025.
7. The PPO investigator issued notices to staff and residents at Edith Rugby House
Approved Premises informing them of the investigation and asking anyone with
relevant information to contact her. No one responded. She obtained copies of
relevant extracts from Ms Fitzpatrick’s prison, probation and AP records.
8. We informed HM Coroner for Greater Lincolnshire, Lincolnshire and Grimsby of the
investigation. He gave us the results of the post-mortem examination. We have sent
the Coroner a copy of this report.
9. The Ombudsman’s office contacted Ms Fitzpatrick’s father to explain the
investigation and to ask if he had any matters he wanted us to consider. He did not
respond.
10. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and we have amended this report
accordingly.
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Background Information
Edith Rigby House Approved Premises
11. Edith Rigby House Approved Premises opened in March 2012. It houses up to 14
women in single rooms. It is a psychologically informed planned environment
(PIPE) and an enabling environment. This involves working with women released
from prison on licence with personality disorders/personality difficulties. The PIPE
model is heavily focused on a relational approach, and as such there is an
expectation of engaging/working even more closely with staff and residents.
12. Residents are responsible for their own healthcare, including registering with a GP.
ERH staff sign the residents up with the GP, they have a good relationship with the
GP practice and work together with regular meetings etc. Residents’ licence
conditions can include a specific curfew, in addition to which Edith Rigby House
requires that residents must be present between 11.00pm and 6.00am. Residents
are required to sign in and out when they leave the premises.
13. Ms Fitzpatrick was the first resident of Edith Rigby House to die since 2012.
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
15. On 26 July 2007, Ms Amanda Fitzpatrick was charged with murder and remanded
to HMP New Hall. On 1 August, Ms Fitzpatrick was convicted and sentenced to a
mandatory life sentence with a minimum term of 15 years. Her sentence was later
reduced on appeal to 13 years and 4 months.
16. On 8 August 2022, Ms Fitzpatrick was released from prison on licence.
17. On 28 December 2023, Ms Fitzpatrick was recalled to HMP New Hall for breach of
licence conditions. At the reception health screening she engaged well with
healthcare staff and stated she had no thoughts of self-harm or suicide. Ms
Fitzpatrick told staff she had been using cocaine every other day and hoped while in
New Hall to become drug free. She was referred for substance use support.
18. Ms Fitzpatrick’s community offender manager (COM) told us that she met Ms
Fitzpatrick and her prison offender manager (POM) regularly, both in person and via
video call during the 14 months she was in prison.
19. On 19 November 2024, Ms Fitzpatrick completed a 16-week Inclusion programme
(intense drug treatment support).
20. On 2 January 2025, Ms Fitzpatrick completed her agreed care plan objectives and
therefore finished her drug treatment in prison. Later in the month, Ms Fitzpatrick
told prison staff that she was okay and felt fine having completed her drug
treatment. There is no record that Ms Fitzpatrick used illicit drugs following her
recall to prison.
21. In January and February, Ms Fitzgerald completed GOALS (a prison programme
run by the gym encouraging healthy living and fitness) and engaged well with the
programme and other participants. She also completed a family resettlement
appointment and spoke positively about her release.
22. On 31 January, Ms Fitzpatrick’s POM confirmed her release to Edith Rigby House
Approved Premises, which was set for 10 March.
23. On 28 February, prison staff spoke with Jobcentre staff in Ms Fitzpatrick’s home
area and arranged for her to attend a drop-in session following release to claim
Universal Credit.
Edith Rigby House Approved Premises
24. On 3 March, Ms Fitzpatrick was released from prison on licence to Edith Rigby
House AP. The COM said that a benefit of this AP was that it was close to where
Ms Fitzpatrick’s family lived, who were a significant source of support for her. Ms
Fitzpatrick said she was happy to be at the AP and staff had made her feel
welcome. As part of her licence conditions, Ms Fitzpatrick was fitted with an
electronic monitoring tag. The COM was on leave when Ms Fitzgerald was
released.
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25. On 4 March, Ms Fitzpatrick attended two induction sessions at Edith Rigby House.
She told staff she no longer had drink and drug issues and was not currently
engaging with substance use support.
26. On 4 March also, the COM returned from leave and completed an initial
appointment with Ms Fitzpatrick via a video call. They discussed whether Ms
Fitzpatrick required substance use support services in the community. Ms
Fitzpatrick had worked with Inclusion at New Hall to address her drug use, and had
remained substance free since, so felt that she did not require additional support at
this stage. The COM said that Ms Fitzpatrick was also concerned that attending
substance use support would place her in contact with other substance users,
therefore increasing her risk of relapse. Ms Fitzpatrick appeared highly motivated to
maintain abstinence from substances and AP staff also supported this assessment
of her.
27. Ms Fitzpatrick was to engage in the therapeutic elements of the AP to assist with
her rehabilitation. She had also been referred to the IIRMS (Intensive Intervention
and Risk Management Service) and Bridging the Gap (aims to break the cycle of
offending, homelessness and addiction by offering trained volunteer mentors to
people at risk of offending, including people who are homeless or addicted). While
the work they would be able to undertake with Ms Fitzpatrick during her stay at the
AP was limited to online contact, it was anticipated that Bridging the Gap
intervention, or an alternative IIRMS provider, would commence once Ms Fitzpatrick
had left the AP. Ms Fitzpatrick’s AP key worker and COM had discussed supporting
Ms Fitzpatrick to develop her personal training qualifications, which would have
benefitted Ms Fitzpatrick in terms of her emotional wellbeing and self-esteem, and
future employment prospects.
28. On 6 March, Ms Fitzpatrick attended another AP induction. AP staff noted that she
was not engaged with substance use services as she was not actively using drugs
and said that she had no need for drink or drugs. Ms Fitzpatrick said she had made
an online Universal Credit claim with a follow up appointment scheduled for
11.00am on the same day. Ms Fitzpatrick also said that she had registered with a
GP.
29. Ms Fitzpatrick told AP staff that she had not used drugs since she was recalled to
prison. Ms Fitzpatrick said that she understood the transition back into the
community could present more opportunity to access illicit substances. AP staff
noted that they would complete three additional welfare checks overnight and, as a
precaution, issued Ms Fitzpatrick with naloxone (to reverse the effects of opiate
overdose).
30. Ms Fitzpatrick provided a drug test which was negative and stated she had not had
cravings. She said that she was not currently engaging with Inspire (local drug and
alcohol service), but said she would let AP staff know if this changed. Staff said that
Ms Fitzpatrick was coping well and attended PIPE meetings and engaged with staff
and other residents.
31. Ms Fitzpatrick’s father told the Coroner that, on 16 March, Ms Fitzpatrick had said
that she wanted to be with her son (who was deceased). However, she did not
make any threats to take her own life or imply any plans to do so and said she had
recently started going to the gym.
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32. On 18 March, Ms Fitzpatrick left the AP and said that she was visiting Scunthorpe
to collect some belongings. She also said that she would visit her family if she had
time.
33. Ms Fitzpatrick did not return by her 7.00pm curfew. The AP manager said she
attempted to call Ms Fitzpatrick as she was surprised given the progress she had
made with them. She asked her team to send Ms Fitzpatrick a text to say that they
were worried about her as she was not back for curfew, and for her to call them
back. The AP manager made further unsuccessful attempts to call Ms Fitzpatrick
and advised her team to allow her until 10.00pm in case of travel issues. However,
she learnt the next day that Ms Fitzpatrick had not returned and had been recalled.
Circumstances of Ms Fitzpatrick’s death
34. On 19 March, Ms Fitzpatrick visited her father’s address. He left the house at
around 1.15pm. Ms Fitzpatrick’s brother returned home from work at 4.00pm and
found her asleep in the bedroom. At around 5.30pm, he entered the bedroom and
saw Ms Fitzpatrick had fallen onto the floor. She had vomited profusely while laid on
her back. Ambulance staff attended and commenced CPR. They transferred her to
hospital where a doctor later pronounced life extinct.
Post-mortem report
35. The post-mortem report concluded that Ms Fitzpatrick died from aspiration of gastric
content (fluids or solid particles go into the windpipe or lungs) caused by
dihydrocodeine (a potent opioid painkiller) overdose.
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Findings
Substance use support
36. Ms Fitzpatrick worked consistently with Inclusion at New Hall to address her
substance use and she seemingly remained drug free during her time in prison
following recall. AP staff said she had a good understanding of the triggers that
threatened her recovery. There is no indication that Ms Fitzpatrick used illicit drugs
or alcohol during her time at Edith Rigby House, or was suspected of doing so,
before her death. AP staff said that she appeared to be progressing well. We are
satisfied that prison and probation staff took appropriate action to support Ms
Fitzpatrick to remain drug free.
Events of 18-19 March 2025
37. On 18 March, Ms Fitzpatrick did not return from her visit to Scunthorpe. Although
AP staff tried to contact her by phone several times, nobody considered that Ms
Fitzpatrick was wearing an electronic tag as part of her licence conditions. Staff did
not discuss contacting the electronic monitoring service provider (EMS) to ask if
they could locate her.
38. In a recent investigation following the death of a resident of a different AP, we
asked EMS if such a request was possible. The EMS Service Manager confirmed
that data can be requested to check someone’s location or trail data. They said an
external agency request would need to be submitted with clear justification for data
to be released, which could be quickly accessed depending on the urgency of the
request.
39. Our report into this death recommended that the Probation Service and EMS should
explore the feasibility of developing an AP protocol to quickly identify the
whereabouts of a resident who does not report for curfew. The recommendation
was accepted and the Probation Service said that work was underway to establish
a direct escalation route to EMS.
Inquest
40. The inquest into Ms Fitzpatrick’s death concluded on 23 December 2025. The
coroner confirmed that Ms Fitzpatrick’s death was drug related.
Adrian Usher
Prisons and Probation Ombudsman March 2026
Prisons and Probation Ombudsman 7
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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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