Bishop, Ian

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Ian Bishop on 4
September 2022, following his
release from HMP Lewes
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
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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 HM 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. Since 6 September 2021, the PPO is investigating post-release deaths that occur
within 14 days of the prisoner’s release.
4. Mr Ian Bishop died of mixed drug toxicity on 4 September 2022, following his
release from HMP Lewes four days earlier. He was 54 years old. We offer our
condolences to those who knew him.
5. When he entered Lewes Mr Bishop told a nurse that he had injected heroin and
crack cocaine that afternoon. He tested positive for cannabis, methadone, opiates
and cocaine.
6. Mr Bishop engaged with substance misuse services at Lewes and healthcare staff
made an appointment for him to attend community substance misuse services after
his release.
7. On 31 August, Mr Bishop was released on licence to his home in Hastings where
he was subject to electronic monitoring and had an electronic tag fitted. Mr Bishop
complied with his curfew conditions.
8. At about 1.00am on 4 September, Mr Bishop’s carer who lived with him at his home
found him unconscious and not breathing in his living room. She telephoned for an
ambulance and started cardiopulmonary resuscitation (CPR). At 1.57am,
paramedics pronounced that he had died.
9. Police attended and found multiple open blister packs of medication, and a bottle of
methadone in the room.
10. A post-mortem examination established that Mr Bishop died from mixed drug
toxicity. Toxicology tests showed fatal levels of methadone in Mr Bishop’s blood at
the time of his death, with abnormally high levels of gabapentin (an anticonvulsant
medication primarily used to treat seizures and nerve pain) and normal levels of
sertraline, mirtazapine (both antidepressants) and quetiapine (anti-psychotic
medication). Cocaine and cannabis were also detected.
Findings
11. Mr Bishop left Lewes without naloxone (used to counter the effects of opioid
misuse).
Prisons and Probation Ombudsman 1
The Investigation Process
12. The PPO investigator obtained copies of relevant extracts from Mr Bishop’s prison
and probation records.
13. We informed HM Coroner for East Sussex of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
14. Mr Bishop had three children who did not want to be involved in the investigation.
15. We shared the initial report with the Prison Service and the Probation Service.
There were no factual inaccuracies.
2 Prisons and Probation Ombudsman
Background Information
HMP Lewes
16. HMP Lewes is a local prison serving the courts of East and West Sussex. It holds
about 600 men. Practice Plus Group provides primary care, mental health and
substance misuse services.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Lewes was in August 2022. Inspectors reported
that primary healthcare lacked effective clinical leadership and was too dependent
on agency staff, leading to gaps in patient care.
18. Despite staffing pressures, inspectors reported that work to progress prisoners in
their sentence was reasonably good. Almost all eligible prisoners had an initial
assessment of their risk and needs. Most sentence plans were relevant and of
reasonable quality. The frequency, and quality, of contact between prison offender
managers (POMs) and prisoners had improved since the last inspection and was
some of the best they had seen recently. Only about 65% of sentenced prisoners
left the establishment with accommodation to go to on their first night of release.
19. In February 2023, Inspectors carried out an independent review of progress and
found that the retention of prison officers and the ability to deploy those still in post
had become critical problems. Aside from activity such as gym sessions or social
visits at least half the prison population spent about 23 hours in their cells every
day.
20. Inspectors reported that healthcare was more encouraging. Many of the failures
they identified in their full inspection had been addressed, and despite the departure
of some managers, staffing had improved.
Probation Service
21. The Probation Service work with all individuals subject to custodial and community
sentences. During imprisonment, they oversee sentence plans 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
appropriate. After release from custody, the probation service supervises people
throughout their licence period and post-sentence supervision.
Prisons and Probation Ombudsman 3
Key Events
22. On 20 July 2022, Mr Ian Bishop was convicted of driving while disqualified and
driving while unfit though drugs and was sentenced to six months in prison.
23. A probation practitioner was appointed as Mr Bishop’s community offender
manager (COM).
24. At his initial health screen, a nurse noted that Mr Bishop had collected his
methadone prescription that morning from his local pharmacy. She noted that Mr
Bishop had injected heroin and crack cocaine that afternoon. Mr Bishop tested
positive for cannabis, methadone, opiates and cocaine. Mr Bishop told her that he
did not use alcohol. The nurse noted that Mr Bishop had epilepsy, depression and
schizophrenia and was referred to a psychiatric nurse in the community. She noted
that in the last twelve months he had self-harmed and had overdosed, but currently
had no thoughts of self-harming.
25. A nurse carried out a mental health review and noted that Mr Bishop might need
help with daily living activities and had a carer in the community. Mr Bishop said
that he was under the care of the Hastings mental health team and had been for
many years.
26. On 21 July, a nurse saw Mr Bishop. She noted that in the community Mr Bishop
received a 70ml supervised dose of methadone. She noted that Mr Bishop should
receive a 30ml dose of methadone followed by a 50ml dose and then a 60ml dose
to treat the symptoms of physical withdrawal from opiates.
27. Healthcare staff saw Mr Bishop daily to review his opiate withdrawal symptoms. A
nurse created a methadone maintenance care plan.
28. On 26 July, a resettlement officer, completed Mr Bishop’s basic custody screen (to
identify the key issues to prioritise in Mr Bishop’s resettlement plan). She noted that
Mr Bishop needed support with sustaining his tenancy (a council property managed
by Optivo Housing). She emailed the housing department at Hastings Borough
Council to try to secure Mr Bishop’s tenancy. She explained that she planned to
recommend that Mr Bishop be released on home detention curfew to his home
address.
29. On 27 July, Mr Bishop was appointed a prison offender manager (POM). On 5
August, The POM met Mr Bishop and explained her role and responsibilities.
30. That same day, a housing officer from Hastings Borough Council referred Mr
Bishop to a prison in-reach co-ordinator with Project Adder (a Home Office initiative
to reduce drug related deaths, drug related offending and drug use in the areas
hardest hit by drug misuse in England).
31. On 24 August, the prison in-reach co-ordinator emailed the COM and confirmed
that Project Adder would help Mr Bishop get to his appointments on the day of his
release. He told Mr Bishop that Project Adder staff would pick him up from Lewes
on his release.
4 Prisons and Probation Ombudsman
32. On 26 August, a GP at Lewes asked the pharmacist if Mr Bishop had received
naloxone (used to counter the effects of opioid misuse) training and who was
responsible for issuing it to Mr Bishop on release. The pharmacist told him that
naloxone would be issued to Mr Bishop by the substance misuse team.
33. On 31 August, a nurse gave Mr Bishop his discharge medication; atorvastatin (to
prevent cardiovascular disease), sodium valproate (for epilepsy), paracetamol,
sertraline (for depression), salbutamol and beclomethasone inhalers (for asthma).
She noted that he had an appointment on 2 September, with Change Grow Live
(CGL- substance misuse service)/STAR (the local community drug and alcohol
recovery team). She sent a discharge summary to Mr Bishop’s community GP.
34. There is no record that Mr Bishop received naloxone on his release from Lewes.
35. Mr Bishop was released on licence from HMP Lewes. Mr Bishop’s licence
conditions required him to report to his COM at Hastings Probation at 12.00pm.
36. Two Project Adder staff met Mr Bishop at the prison and took him to the Hastings
Probation Office for his probation appointment and then took him to his appointment
with the Department for Work and Pensions so that he could arrange his benefits
claim.
37. At his initial probation appointment, the COM explained the terms of his licence and
completed the induction paperwork. She explained that Mr Bishop would be subject
to home detention curfew (a scheme that enables eligible prisoners to be released
before they have completed half their sentence, subject to an electronically
monitored curfew) between 7.00pm and 7.00am each day at his home address. Mr
Bishop’s licence conditions also required him to provide samples for drug tests
whenever required. She told Mr Bishop that he needed to be at home by 3.00pm,
so that his electronic tag could be fitted.
38. That evening, a member of staff from Electronic Monitoring Services (EMS) went to
Mr Bishop’s home and fitted his electronic tag.
39. On 2 September, Mr Bishop telephoned the Hastings Probation Office and told staff
that he was unable to go to his STAR appointment because his transport hadn’t
turned up.
40. EMS records show that Mr Bishop complied with his curfew.
Circumstances of Mr Bishop’s death
41. At about 1.00am on 4 September, Mr Bishop’s live-in carer, found him unconscious
and not breathing in the living room. She called for an ambulance. Paramedics went
to his home and attempted to resuscitate him but at 1.57am, the paramedics said
that he had died.
42. Police attended and found multiple blister packs and bags of opened medication,
including a bottle of methadone in the room in which Mr Bishop died.
Prisons and Probation Ombudsman 5
Post-mortem report
43. A post-mortem examination established that Mr Bishop died from mixed drug
toxicity.
44. Toxicology tests showed fatal levels of methadone in Mr Bishop’s blood at the time
of his death with abnormally high levels of gabapentin (which he was not
prescribed) and the presence of normal levels of sertraline, mirtazapine and
quetiapine. Cocaine and cannabis were also detected.
Inquest
45. At an inquest held on 19 January 2024, the Coroner concluded that Mr Bishop’s
death was drug related.
Support for staff
46. After Mr Bishop’s death the COM’s line manager reminded her of the available
support services.
Contact with Mr Bishop’s family
47. Mr Bishop had three children who told the Coroner’s officer that unless his cause of
death was from a hereditary disease they did not wish to be contacted regarding his
death. Mr Bishop’s funeral took place on 1 February 2023 and was paid for by the
local authority.
Head of Healthcare to note
Substance misuse
48. Mr Bishop had a history of substance misuse, was convicted of a drug related
offence and tested positive for cannabis, methadone, opiates and cocaine when he
entered Lewes. Mr Bishop engaged with substance misuse services and healthcare
staff appropriately arranged the continuity of this care in the community.
49. Five days before his release, a GP at Lewes asked a pharmacist if Mr Bishop had
received naloxone training and if he should issue naloxone to him or if it would be
handed to him as he was released. The pharmacist told him that naloxone would be
issued to Mr Bishop by the substance misuse team.
49. There is no evidence that Mr Bishop received naloxone on release. The Head of
Healthcare said that, since Mr Bishop’s death, a new process had been introduced
for issuing naloxone to prisoners on release. Prisoners on a substance misuse
programme at Lewes are given naloxone training, which remains valid for six
months. Naloxone is then handed to a prisoner in reception when they are released.
She said that there is an NHS reporting process to monitor the number of prisoners
issued with naloxone.
Given that a new process is now in place, it is appropriate to allow that process to
embed. We make no recommendation, but the Head of Healthcare will want to
6 Prisons and Probation Ombudsman
assure herself that it is robust, for example by conducting quality assurance checks
on leaving prisoners.
Adrian Usher
Prisons and Probation Ombudsman September 2023
Prisons and Probation Ombudsman 7
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