Andrew Clark

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Andrew Clark
on 16 April 2022, following his
release from HMP Peterborough
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. 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.
4. Mr Andrew Clark died of sudden unexpected death in alcohol use on 16 April 2022,
two days after his release from HMP Peterborough. He was 55 years old. We offer
our condolences to those who knew him.
5. Mr Clark received good support with his alcohol misuse issues at Peterborough. He
completed an alcohol detoxification and was appropriately monitored during that
time. Prior to his release, he was offered a referral to a community substance
misuse service but declined.
6. Due to staff shortages and high caseloads, a community offender manager (COM)
was allocated to Mr Clark only nine days before his release, which allowed very little
time for pre-release planning. We are satisfied that this had minimal impact as
accommodation had already been arranged for Mr Clark and no referrals were
needed.
7. We make no recommendations.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
8. HMPPS notified us of Mr Clark’s death on 6 October 2022.
9. The PPO investigator obtained copies of relevant extracts from Mr Clark’s prison
and probation records.
10. We informed HM Coroner for Northamptonshire of the investigation. She gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
11. The Ombudsman’s office contacted Mr Clark’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. He did not respond.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Peterborough
13. HMP Peterborough is a local and resettlement category B prison which holds
prisoners who have either been convicted or are on remand. It is managed by
Sodexo.
Probation Service
14. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
15. On 1 February 2022, Mr Andrew Clark was convicted of sending letters with intent
to cause distress or anxiety and was sentenced to 21 weeks in prison. He was sent
to HMP Peterborough.
16. When Mr Clark arrived at Peterborough, he told the reception nurse that he was an
alcoholic and drank alcohol every day. The nurse referred Mr Clark to the alcohol
misuse clinic, and he was placed in a cell in the healthcare unit, so he could be
monitored by healthcare staff.
17. That day, a nurse from the substance misuse team completed Mr Clark’s initial
assessment. Mr Clark said he had drunk alcohol every day for a long time and
could not remember when he started. The nurse noted that Mr Clark had had a
withdrawal induced seizure while in court custody earlier that day and that he had
been given diazepam (medication used to treat seizures and alcohol withdrawal
syndrome).
18. On 3 February, a nurse saw Mr Clark. He said he had been binge-drinking since he
was a child and had engaged with Substance to Solution (an organisation providing
support to people with drug and alcohol issues) a few times in the community, but
never for very long. Mr Clark had a prosthetic leg and was a wheelchair user. The
nurse noted that along with poor mobility, he was overweight, had chronic
obstructive pulmonary disease (COPD – the term for a group of serious lung
diseases) and chronic gout. The nurse noted that she would discuss acamprosate
with Mr Clark (a medication that reduces alcohol cravings) once he was feeling
better and gave him a leaflet about it. There is nothing in his medical record that
indicates a further discussion was held.
19. A GP put Mr Clark on an alcohol detoxification programme and prescribed him
chlordiazepoxide (medication used to treat alcohol withdrawal symptoms) and
thiamine (vitamin B1). Mr Clark completed his detoxification on 9 February.
20. Healthcare staff monitored Mr Clark daily. He did not present with any more
withdrawal symptoms once he finished his detoxification.
Pre-release planning
21. On 23 February, a recovery worker from the substance misuse team completed a
basic assessment with Mr Clark. During the assessment, Mr Clark said he did not
want a referral to a community substance misuse service and all he needed help
with was sorting out his housing. A resettlement worker subsequently arranged for
Mr Clark’s supported housing to be available to him on his release.
22. On 5 April, a community offender manager (COM) was allocated to Mr Clark, only
nine days prior to his release. The investigator spoke with the COM’s line manager
who said the case was allocated late due to staff shortages and high caseloads at
the time.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
23. Due to the long waiting times for videolink appointments, the COM was unable to
book a videolink with Mr Clark to discuss release planning with him. She issued him
with an initial appointment to attend the probation office on the day of his release.
Post-release management
24. On 14 April, Mr Clark was released from Peterborough. Mr Clark’s COM called him
that day after he did not attend his initial appointment at the probation office. Mr
Clark said he had not been told that he needed to attend the office and was
adamant he would not attend. The COM said Mr Clark sounded under the influence
of alcohol, but he denied this. She told Mr Clark that she would complete a home
visit and would call him when she was outside. However, the COM’s manager
advised her not to do the home visit due to Mr Clark being under the influence of
alcohol and aggressive over the phone.
25. Mr Clark was released the day before the Easter weekend, so the next working day
was the following Tuesday. Mr Clark died over the Easter weekend so was not seen
by probation following his release.
Circumstances of Mr Clark’s death
26. On 16 April, a member of supported housing staff visited Mr Clark’s address for a
welfare check. He had to force entry into the house because he did not get a
response from Mr Clark.
27. Mr Clark was found unresponsive in his bedroom. An ambulance was called, and
Mr Clark was declared dead at 3.50pm.
Post-mortem report
28. The post-mortem report concluded that Mr Clark died of sudden unexpected death
in alcohol use. Cardiac hypertrophy and obesity were listed as contributing factors.
29. The coroner concluded no inquest was required.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
30. We are satisfied that the prison supported Mr Clark with his alcohol misuse issues.
The nurse appropriately referred Mr Clark to the alcohol misuse clinic and the GP
promptly placed Mr Clark on alcohol detoxification. The healthcare team at
Peterborough regularly checked on Mr Clark and monitored him appropriately on
the daily ward rounds. Prior to his release, a recovery worker offered Mr Clark a
referral to a community substance misuse service, but he declined.
31. Due to staff shortages and high caseloads, a COM was not allocated to Mr Clark
until nine days before his release. This left very little time for pre-release planning
and the COM was unable to book a videolink appointment with Mr Clark in the short
time available. However, we note that Mr Clark already had accommodation
arranged and no referrals were needed. Therefore, the late allocation had minimal
impact in this case.
32. Mr Clark was released on the Thursday before the Easter weekend, which meant
that the next working day was not for five more days, on the Tuesday. Since then,
the Ministry of Justice has announced the end to releases on Fridays and days
preceding bank holidays. This is to enable newly released prisoners to access
essential services before they close for the weekend.
33. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman September 2024
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE