Andrew Flanagan

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Andrew Flanagan
on 16 July 2023,
following his release from
HMP Wormwood Scrubs
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
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. 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 Flanagan died of heroin and cocaine toxicity on 16 July 2023 following
his release from HMP Wormwood Scrubs on 7 July. He was 39 years old. We offer
our condolences to those who knew him.
5. We found that Mr Flanagan received good support with his substance misuse
issues at Wormwood Scrubs. As Mr Flanagan was unexpectedly released from
court due to serving the custodial part of his sentence while on remand, he did not
have an allocated community offender manager until after his release. As a result,
no release planning was completed.
6. We found no issues of concern. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Flanagan’s death on 20 September 2023.
8. The PPO investigator obtained copies of relevant extracts from Mr Flanagan’s
prison and probation records.
9. We informed HM Coroner for West London of the investigation. They gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
10. The Ombudsman’s family liaison officer contacted Mr Flanagan’s next of kin, his
father, to explain the investigation and to ask if he had any matters he wanted us to
consider. He had no questions but asked for a copy of our report.
11. We shared our initial report with HMPPS. They found no factual inaccuracies.
12. We sent a copy of our initial report to Mr Flanagan’s father. He did not notify us of
any factual inaccuracies.
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Background Information
HMP Wormwood Scrubs
13. HMP Wormwood Scrubs is a category B local male prison, with an operational
capacity of 1,273. The prison accepts sentenced and remand prisoners over the
age of 21 as well as young adults (18-21 years old) on remand only. Practice Plus
Group (PPG) provides primary healthcare services, the Forward Trust provides
substance misuse services, and Barnet, Enfield and Haringey NHS Mental Health
Trust provides mental health services.
HM Inspectorate of Prisons
14. The most recent inspection of HMP Wormwood Scrubs was in June 2021.
Inspectors reported that the drug strategy group was pursuing a refreshed and
coherent whole-prison approach to tackle substance misuse, with the Forward Trust
and PPG providing psychosocial and clinical treatment, respectively, for prisoners
with drug or alcohol problems. Working relationships between the Forward Trust
and PPG were good, and joint reviews of the current caseload of 180 prisoners in
receipt of opiate substitution treatment took place at appropriate milestones.
Individualised discharge planning and support were provided, with overdose training
and a supply of naloxone (an opiate reversal agent) provided where appropriate.
Links were made with community providers and arrangements to maintain
treatment post-release were delivered consistently.
Probation Service
15. 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.
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Key Events
16. On 13 February 2023, Mr Andrew Flanagan was remanded to HMP Wormwood
Scrubs.
17. On 7 July, Mr Flanagan attended court and was convicted of criminal damage and
was sentenced to six weeks in prison. As he had already served the custodial part
of his sentence while on remand, he was released from court the same day.
Substance misuse services
18. Mr Flanagan was a drug user. When he arrived at Wormwood Scrubs, a GP
diagnosed him as having multiple drug dependencies and prescribed him a
methadone detoxification programme (opioid medication used to treat the
symptoms of heroin withdrawal). The GP referred him to the prison substance
misuse service, the Forward Trust.
19. On 14 February, a Forward Trust recovery worker completed an initial assessment
with Mr Flanagan. They warned Mr Flanagan about the risks associated with taking
drugs and he agreed to work with them. The recovery worker told Mr Flanagan
about the importance of complying with his treatment plan and advised him of the
benefits of engaging with the Forward Trust and community drug teams. Later that
day, Mr Flanagan was allocated a Forward Trust keyworker.
20. On 24 February, Mr Flanagan’s keyworker saw him, and they agreed on a
treatment recovery plan. They discussed the risks associated with taking illegal
drugs and discussed tolerance levels and the risks of overdosing. The keyworker
told Mr Flanagan about naloxone (a medication that can rapidly reverse the effects
of an overdose of heroin or other opioids), and Mr Flanagan said he would like to be
released with a supply of this. Although Mr Flanagan was not yet sentenced and
therefore had no release date, the keyworker sent an alert to the local community
substance misuse service.
21. As Mr Flanagan’s keyworker knew that he was due to go to court on 13 March and
that he might be released, she arranged an appointment for him at a local
substance misuse service, Ealing RISE, for 14 March. Mr Flanagan did not get
released on this date, so the appointment did not go ahead.
22. Over the next two months, Mr Flanagan engaged with the Forward Trust, completed
recovery workbooks around relapse prevention and was compliant with his
methadone detoxification programme.
23. On 7 July, Mr Flanagan was summoned to court, sentenced, and released the
same day. The investigator could not find any evidence that he was issued with a
take-home naloxone kit.
Release from Wormwood Scrubs
24. On 7 July, Mr Flanagan attended Harrow Probation office. As he was released
straight from court, he had not yet been allocated a community offender manager
(COM). The probation practitioner on duty completed his induction and explained
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the conditions on his licence. Mr Flanagan signed to say that he understood and
gave the probation practitioner his updated address and telephone number. They
told Mr Flanagan that once he was allocated a COM, they would contact him to give
him his next appointment.
25. On 12 July, Mr Flanagan was allocated a COM. She sent him a letter with the
details of his next appointment which was scheduled for 14 July.
26. On 14 July, Mr Flanagan did not attend his appointment with his COM. She sent
him a breach letter and issued him another appointment. (Mr Flanagan did not
attend this appointment as he had already died.)
Circumstances of Mr Flanagan’s death
27. On 16 July, a member of the public rang the police to say that they had seen a body
lying unresponsive in a bush near an underpass in Northolt. Paramedics attended
and declared Mr Flanagan deceased at approximately 3.20pm.
28. On 11 September, a friend of Mr Flanagan’s family informed HMPPS that he had
died.
Post-mortem report
29. The post-mortem report concluded that Mr Flanagan died of heroin and cocaine
toxicity.
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Findings
30. Mr Flanagan had a history of substance misuse. While he was in prison, he was
seen regularly by the Forward Trust and warned about the risks and dangers of
taking drugs. He was also trained in the use of naloxone. As Mr Flanagan was
unexpectedly released straight from court, it is not known if he was given a
naloxone kit. There is currently no process in place to ensure that those at risk of
opiate overdose are released from court with naloxone. HMPPS and HM Courts
and Tribunal Service (who are responsible for the management of courts, and who
have been sent a copy of this report) will wish to consider this further.
31. We are satisfied that both the prison and probation services did all they could to
manage the risks associated with Mr Flanagan’s substance misuse.
32. We make no recommendations.
Corrections:
Following the inquest, HMPPS notified us that Mr Flanagan appeared in court by
video link, not in person, and was therefore released from the prison, not the court.
They told us that HM Courts and Tribunals Service (HMCTS) are not responsible for
the welfare of a defendant whilst in custody or at the point of their release.
Therefore, HMCTS would not have been responsible for making sure Mr Flanagan
had access to naloxone even if he had attended court for his sentencing.
They also notified us that Mr Flanagan attended his probation appointment on 10
July, not 7 July.
Adrian Usher
Prisons and Probation Ombudsman March 2024
Inquest
The inquest, held on 18 June 2024, concluded that Mr Flanagan’s death was drug related.
6 Prisons and Probation Ombudsman
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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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