Clifton, Lee

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Lee Clifton
on 25 June 2022, following his
release from HMP Lindholme
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
© 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.
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. On 6 September 2021, the PPO started investigating post-release deaths that occur
within 14 days of the prisoner’s release.
4. Mr Lee Clifton died of mixed drug toxicity on 25 June 2022 following his release
from HMP Lindholme on 23 June 2022. He was 43 years old. I offer my
condolences to those who knew him.
5. Mr Clifton was recalled to prison on 26 August 2020, for committing a further
offence while on licence. He had a long history of substance use and an extensive
offending history, which was predominantly linked to his substance misuse. Mr
Clifton was dependent on heroin and cocaine and when he returned to prison, he
was highly motivated to engage with the Substance Misuse Team. He completed a
methadone and alcohol detoxification programme and was prescribed mirtazapine
for low mood and difficulties sleeping.
6. Mr Clifton’s recall was reviewed, and the Parole Board directed his re-release. On
23 June 2022, Mr Clifton was released to CAS3 accommodation (for people leaving
prison who would otherwise be homeless) in his local area. He was also working
with a community housing service, Nacro, to secure more permanent
accommodation. He had additional licence conditions which required him to engage
with the community substance misuse team, Aspire, and comply with drug testing.
An initial appointment with Aspire was arranged for the day after his release. Mr
Clifton was offered naloxone for his release, which he refused, and a number of
other opioid substitution treatments were discussed and offered to him. However,
Mr Clifton’s preferred option was not available in his release area. Mr Clifton was
released with a supply of mirtazapine, but without opioid substitution treatment.
7. A duty officer at the probation office met with Mr Clifton for his initial appointment on
23 June.
8. On 27 June, Mr Clifton’s sister informed his Community Offender Manager (COM)
that Mr Clifton had died on 25 June.
9. We did not find any issues of concern and identified good practice by the substance
misuse worker at Lindholme.
Prisons and Probation Ombudsman 1
The Investigation Process
10. HMPPS notified us of Mr Clifton’s death on 27 June 2022. The PPO investigator
obtained copies of relevant extracts from Mr Clifton’s prison and probation records.
11. We informed HM Coroner for South Yorkshire, Eastern District of the investigation.
She gave us the results of the post-mortem examination. We have sent the Coroner
a copy of this report.
12. The Ombudsman’s family liaison officer contacted Mr Clifton’s next of kin, his sister
to explain the investigation and to ask if she had any matters she wanted us to
consider. She did not respond.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
2 Prisons and Probation Ombudsman
Background Information
HMP Lindholme
14. HMP Lindholme is a category C/D prison near Doncaster, with capacity to hold up
to 935 adult male prisoners. Practice Plus Group provides healthcare services, with
healthcare staff on duty between 7.30am and 7.30pm every day. Practice Plus
Group are also the substance use treatment provider.
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 supervises people
throughout their licence period and post-sentence supervision.
Prisons and Probation Ombudsman 3
Key Events
16. On 14 July 2017, Mr Lee Clifton was convicted of burglary and was sentenced to six
years in prison. On 12 June 2020, he was released from HMP Kirkham. On 27
August, Mr Clifton was recalled to prison for burglary and was sent to HMP
Doncaster.
17. When Mr Clifton arrived at Doncaster, a nurse completed an initial health screen.
She noted that there were wounds to his lower leg from injecting drugs. (While in
police custody, he had been taken to hospital and prescribed antibiotics.) Mr Clifton
said that he had a history of depression and substance misuse, and at that time, he
was using ten £5 bags of heroin daily, as well as daily crack cocaine which he
would occasionally ‘speedball’ (a combination of cocaine and heroin). Mr Clifton
also reported drinking half a bottle of spirits daily.
18. That day, a nurse completed an initial substance misuse assessment. Mr Clifton
was assessed as being cocaine and heroin dependant. He also used psychoactive
substances and alcohol. The nurse prescribed Mr Clifton methadone maintenance
therapy and alcohol detoxification, chlordiazepoxide (a medication of the
benzodiazepine class used to treat withdrawal from alcohol and other drugs),
flucloxacillin (for his injection wounds) and thiamine (a B vitamin).
19. Healthcare staff referred Mr Clifton for a psychosocial substance misuse
assessment, which took place on 3 September with a recovery worker. They also
referred him to Aspire, a community drug and alcohol team. The recovery worker
gave Mr Clifton lifestyle advice about harm minimisation and the potential risk of
overdose. They discussed naloxone (a medication used to reverse or reduce the
effects of opioids) and Mr Clifton agreed to look into this for his release.
Pre-release planning
20. On 5 October 2020, Mr Clifton was transferred to HMP Lindholme.
21. Mr Clifton was allocated a Prison Offender Manager (POM).
22. Mr Clifton remained engaged with the substance misuse team and complied with
his methadone detoxification programme. On 21 December 2020, Mr Clifton
contacted healthcare staff to discuss reducing his methadone dose. Healthcare staff
scheduled an appointment for 23 December where it was agreed that his dose
would be reduced by 5ml to 35ml. Over the months that followed, his methadone
dosage was gradually reduced, and on 10 December 2021, his dosage was
reduced to 2ml.
23. On 17 January 2022, Mr Clifton told healthcare staff that he had decided to stop
taking his methadone. Healthcare staff prescribed promethazine hydrochloride for
two weeks to help with the side effects he was experiencing, including difficulties
sleeping.
24. On 25 January, Mr Clifton was allocated a Community Offender Manager (COM).
4 Prisons and Probation Ombudsman
25. Mr Clifton engaged with a structured psychosocial intervention session on 7
February. They discussed plans for release and Mr Clifton acknowledged that when
he had no firm plans, he would return to drug use and would mix with other known
users, he said that he needed to secure accommodation and employment to give
him the best chance of success.
26. On 14 March, the COM met with Mr Clifton using video link. As a recalled prisoner,
Mr Clifton was subject to regular reviews of his recall. The COM used this meeting
to gather information for the Parole Board review, which she submitted on 16
March. She supported Mr Clifton’s release, pending securing accommodation, and
noted the positive steps he had taken in custody to address his risk factors,
including engagement with services, stabilising his mental health, and maintained
abstinence from drugs.
27. The Parole Board directed Mr Clifton’s release. His release date was arranged for
23 June to allow Nacro time to provide accommodation.
28. On 5 May, Mr Clifton approached healthcare staff and told them that he had been
granted parole and would be released on 23 June. He said that he would like to be
given Buvidal (a monthly injection used to treat dependence on opioid drugs such
as heroin). Mr Clifton felt that this medication would help him remain drug free as he
would not need to attend drug services daily to collect it. He felt bumping into other
drug users at the chemist was a trigger for him. In preparation for him to receive this
medication, healthcare staff arrange for him to have an ECG and an appointment
for blood work. The appointment for blood work took place the following day. The
ECG took place on 19 May.
29. Also on 19 May, staff from the substance misuse team saw Mr Clifton. They
discussed the Buvidal injection and explained how it worked. They also discussed
naloxone, but Mr Clifton said that it was not something he was interested in at that
time. Mr Clifton said he was anxious about being released. He said that he had
used Subutex two weeks previously, which he put down to anxiety about being
released. Mr Clifton was unsure about where he would live on release and was
hoping to hear from the Offender Management Unit (OMU) about this. During the
meeting, the substance misuse worker chased OMU on his behalf. OMU responded
and said that there was no update at that time.
30. On 20 May, a substance misuse practitioner made a referral to Aspire community
drug and alcohol services. She told them that Mr Clifton was due to commence
Buvidal prior to release and would need support from the service. Aspire provided
an appointment for 24 June, the day after Mr Clifton’s release, but advised her that
they did not prescribe Buvidal, so offered buprenorphine instead. She enquired
about Espranor (another medication containing buprenorphine). Aspire said that not
many pharmacies stocked it, which would limit where Mr Clifton could collect it from.
31. Two days later, the substance misuse practitioner met with Mr Clifton to discuss the
feedback from Aspire. Mr Clifton said he was set on Buvidal and did not want to
attend a chemist to collect medication daily. She discussed the risk of being
released without any opioid substitution treatment, but Mr Clifton said he did not
want to be placed on any medication other than Buvidal, which was no longer an
option. He was offered naloxone, which he declined.
Prisons and Probation Ombudsman 5
32. The substance misuse practitioner contacted Mr Clifton on 23 May after she had
liaised with the prescriber. She discussed naltrexone (a medication which blocks
the effects of opioid use and therefore reduces the urge to use them), but Mr Clifton
said that he had tried this before and did not want it again. She suggested that Mr
Clifton be prescribed Espranor for release and then swap to buprenorphine in the
community. Mr Clifton refused because he did not want to attend the chemist daily.
She explained to Mr Clifton that he could have naltrexone in possession, however
he declined the offer and said that it had made him feel ill when he had tried it
previously.
33. The substance misuse practitioner discussed Mr Clifton’s concerns with a senior
pharmacist and a pharmacy lead and sought guidance on Mr Clifton’s options. She
had identified the risk of overdose if he was not medicated. The pharmacy lead was
not comfortable agreeing to prescribe Buvidal without support from key staff and
suggested Mr Clifton could be prescribed weekly amounts of Espranor. Mr Clifton
later refused this offer.
34. On 17 June, the COM completed a duty to refer (DTR) form (The Homelessness
Reduction Act 2017 requires prisons and probation services to refer anyone who is
homeless or at risk of becoming homeless within 56 days to a local housing
authority) to the local authority as no settled accommodation had been identified for
Mr Clifton yet. She also made a referral for CAS3 accommodation (which provides
temporary accommodation for up to 84 nights for homeless prison leavers). She
recorded in the referral that Mr Clifton was working with Nacro to secure more
permanent accommodation.
35. The next day, the substance misuse practitioner saw Mr Clifton for his final
appointment. He said that he felt good, albeit nervous about his release. She asked
if he wanted to take home naloxone, which he refused (the reason for his refusal
was not recorded). They discussed naltrexone and she advised him that he could
request this in the community, but he refused this. They discussed post release
risks and Mr Clifton said that he was aware of his tolerance and that he had no
intention to use drugs. She encouraged him to maintain contact with throughcare
services.
36. On 20 June, a CAS3 release address was secured for Mr Clifton. The COM
assessed it as suitable and asked the POM to inform Mr Clifton. The
accommodation was in his local area, within one mile of the probation office and
Aspire. Mr Clifton attended the OMU the following day, and he met with the POM.
He signed his licence and was given the details of the release address.
37. On 23 June, a nurse saw Mr Clifton in preparation for his release. He told the nurse
that he had temporary accommodation and a job interview later that day. The nurse
described his mental health as good and prescribed him with a supply of
mirtazapine.
38. That day, Mr Clifton was released from HMP Lindholme. He had additional licence
conditions which required him to engage with Aspire and comply with drug testing.
6 Prisons and Probation Ombudsman
Post-release
39. Following his release from Lindholme, Mr Clifton reported to Doncaster Probation
Office as directed. He had an initial supervision appointment with the duty officer, in
his COM’s absence. Mr Clifton presented well and engaged in the session. He
completed the induction paperwork and was given a copy of the CAS3
accommodation offer letter. The duty officer issued Mr Clifton with his next
appointment for 27 June and provided him with a telephone number should he
experience any difficulties finding or settling into his new accommodation.
40. An appointment was made for Mr Clifton to attend Aspire on 24 June. He did not
attend this appointment or make contact with them following his release.
41. On 27 June, Mr Clifton’s sister contacted the COM to notify her of Mr Clifton’s
death. She told her that Mr Clifton had died from a suspected heart attack two days
earlier.
Circumstances of Mr Clifton’s death
42. At 8.35pm on 25 June, an unknown female called the ambulance service to report a
male struggling to breathe, gurgling, and choking. An ambulance arrived at the
address and found drug paraphernalia and discarded needles. Mr Clifton was taken
to hospital by emergency ambulance and went into cardiac arrest. At 10.38pm, it
was confirmed that Mr Clifton had died. Paramedics who attended the scene
believed that Mr Clifton might have been taking drugs with two occupants
immediately prior to his death.
Post-mortem report
43. The post-mortem report concluded that Mr Clifton died of mixed drug toxicity.
Toxicology tests showed that Mr Clifton had used cocaine, benzoylecgonine,
mirtazapine, morphine, codeine, pregabalin, bromazolam and etizolam. The
toxicology report said that the time Mr Clifton had spent in prison custody, might
have led to a loss of tolerance to these various drugs leading to the combined
toxicity from morphine (opiate), along with pregabalin, and the benzodiazepines.
The report also noted that Mr Clifton had also used of cocaine and that this
potentially could have created the risk of sudden death from mixed drug toxicity.
Inquest
44. At an inquest held on 21 June 2023, the Coroner concluded that Mr Clifton’s death
was drug related.
Support for staff
45. The COM and POM reported that they were both offered support from their
managers following the death of Mr Clifton. The COM said that she was also
directed to the workplace counselling service, PAM Assist.
Prisons and Probation Ombudsman 7
Contact with Mr Clifton’s family
46. Mr Clifton’s family were advised to go to the hospital following a telephone call from
an unknown associate of Mr Clifton. Because Mr Clifton was not carrying any
identification, the hospital could not confirm that he was a patient. The family
contacted the police with their concerns. There was a delay in informing them of Mr
Clifton’s death due to difficulties in identifying him.
47. Following Mr Clifton’s death, the COM offered her condolences to Mr Clifton’s family
on behalf of the Probation Service.
Findings
Good practice
48. Mr Clifton had a long history of drug and alcohol dependence. We are satisfied that
Mr Clifton was appropriately assessed by a substance misuse nurse on the day he
was returned to prison. He started a methadone and alcohol detoxification
programme immediately and remained engaged with the substance misuse team
throughout his time in prison. He successfully completed a methadone
detoxification programme and received ongoing support in this area. A referral was
made to Aspire community drug and alcohol team prior to his release, with an initial
appointment scheduled for the day after release. He was also subject to appropriate
additional licence conditions directing engagement with Aspire and compliance with
drug testing.
49. The substance misuse worker recognised the risk of potential overdose and made
extensive and commendable efforts to explore and encourage opioid substitution
treatments, liaising with others to explore alternatives. Mr Clifton left prison without
a prescription for opioid substitution therapy by his own choice. The substance
misuse worker offered Mr Clifton naloxone on several occasions prior to his release,
however he refused this.
50. Probation practitioners arranged suitable, temporary accommodation for Mr Clifton
prior to his release, and that ongoing work was underway to obtain more permanent
accommodation. Mr Clifton received appropriate support in prison and was referred
to appropriate services in the community on release.
Adrian Usher
Prisons and Probation Ombudsman January 2024
8 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