McLoughlin, Daniel

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Daniel
McLoughlin, on 21 December
2022, following his release from
HMP Leeds
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. Since 6 September 2021, the PPO is investigating post-release deaths that occur
within 14 days of the prisoner’s release.
3. 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.
4. Mr Daniel McLoughlin was found hanged in accommodation in Keighley, West
Yorkshire, on 21 December 2022, following his release from HMP Leeds eight days
earlier. He was 50 years old. We offer our condolences to his family and friends.
5. Mr McLoughlin had few risk factors for suicide and self-harm. He was not managed
under HMPPS suicide and self-harm prevention procedures (known as ACCT) at
Leeds or during any previous time in prison. However, Mr McLoughlin was
diagnosed with anxiety and depression and received medication for this. He had a
history of using illicit drugs and was in debt in the community as a result.
6. We are satisfied that there was little to indicate that Mr McLoughlin was at
heightened risk of suicide in the time leading up to his death or that there was any
specific risk information that should have been shared between prison staff and his
community offender manager or support agencies.
7. We did not find any issues of concern.
Prisons and Probation Ombudsman 1
The Investigation Process
8. The PPO investigator obtained copies of relevant extracts from Mr McLoughlin’s
prison and probation records.
9. We informed HM Coroner for West Yorkshire (West) of the investigation. He 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 wrote to Mr McLoughlin’s mother to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond.
11. We shared the initial report with HM Prison and Probation Service. There were five
factual inaccuracies.
2 Prisons and Probation Ombudsman
Background Information
HMP Leeds
12. HMP Leeds is a local prison holding a maximum of 1,110 prisoners on remand,
convicted or sentenced. The prison serves the courts of West Yorkshire. Practice
Plus Group provides healthcare services, including mental health services.
HM Inspectorate of Prisons
13. The most recent full inspection of HMP Leeds was in June 2022, inspectors
reported that prisoners sentenced to over a year in prison should have moved on to
other prisons to access more intensive offender management support and offending
behaviour work but, due to the lack of places elsewhere, many stayed at Leeds for
too long. As some prisoners experienced long delays in moving on to training
prisons, a few Prison Offender Managers had delivered some offence-focused
interventions to promote prisoners’ progression. Inspectors reported that there was
no specific practical support on the day of release other than a stock of clothing that
prisoners could choose from if they had little of their own to wear.
14. In July 2023, inspectors conducted an independent review of progress at Leeds.
They reported that prison managers had secured funding to develop the
employability skills of prisoners nearing release. While support for prisoners’
resettlement needs had improved, inspectors found that much work between
community agencies and prison staff was uncoordinated.
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 which, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervises people
throughout their licence period and post-sentence supervision.
HM Inspectorate of Probation
16. The most recent inspection of the West Yorkshire Community Rehabilitation
Company (WYCRC) (in June 2021, the WYCRC became part of a unified Probation
Service Yorkshire and the Humber) was in March 2020. Inspectors reported that
staffing levels and staff development required urgent attention to raise the quality of
work with individuals. Inspectors were disappointed that a new case management
and assessment system, commissioned through a private supplier, had not been
and would not be available to use.
Prisons and Probation Ombudsman 3
Key Events
17. On 4 November 2019, Mr Daniel McLoughlin was convicted of burglary and
sentenced to five years and three months in prison. On 17 June 2022, Mr
McLoughlin was released on licence. His licence was revoked on 17 November,
and he was recalled to HMP Leeds. Mr McLoughlin’s prison records did not contain
any markers identifying a history or risk of suicide and self-harm, and he had never
been monitored under suicide and self-harm prevention procedures (known as
ACCT).
18. At his initial health screen, Mr McLoughlin told a nurse that he had anxiety and
depression. Mr McLoughlin said that he used illicit drugs and bought £60 of heroin
and crack cocaine daily. He later said that he had injected heroin and crack cocaine
the day before he entered custody. Mr McLoughlin said that he was under the care
of a community substance misuse team where he received a methadone
prescription. The nurse referred Mr McLoughlin to the psychosocial substance
misuse service.
19. On 18 November 2022, a nurse saw Mr McLoughlin for substance misuse support.
She recorded a Clinical Opiate Withdrawal Scale (COWS) score of 16, which
indicated moderate opiate withdrawal. She telephoned Mr McLoughlin’s community
pharmacist, who said that he had a prescription for 70ml of methadone per day.
Another nurse prescribed Mr McLoughlin incremental doses of methadone in
accordance with the induction regime.
20. On 23 November, a probation service officer, who was Mr McLoughlin’s community
offender manager (COM), referred him to Bradford District Council because he said
that he would be released homeless. (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.)
21. On 25 November, Mr McLoughlin was allocated a prison offender manager.
22. On 25 November, a probation service officer noted that Mr McLoughlin was
previously living in a council flat but had been evicted because he had not paid the
service charge. Mr McLoughlin said that he would like support to find
accommodation on release. The officer made a Commissioned Rehabilitative
Services (CRS, who coordinate the process to find accommodation for prisoners
being released homeless) referral to St Giles Trust (a registered charity which
delivers personal wellbeing services and support the Probation Service in reducing
re-offending). Mr McLoughlin said that he had significant debts before he came into
custody. The officer made a referral to the Growth Company (a social enterprise
with a mission to create jobs, education opportunities and rehabilitative support) for
finance, benefit and debt support. He also referred Mr McLoughlin to Ingeus (who
deliver services across employment, health, justice and youth) for personal
wellbeing support.
23. On 1 December, the COM referred Mr McLoughlin to the Community
Accommodation Service (CAS3, which provides temporary accommodation for up
to 84 nights for homeless prison leavers).
4 Prisons and Probation Ombudsman
24. On 8 December, Mr Loughlin told an Ingeus mentor that he felt anxious about his
release because he was unsure if he would have accommodation. Mr McLoughlin
asked for help to claim Universal Credit. He told her that he would like training to
keep him focused and away from drugs and agreed to look at training for a
Construction Skills Certification Scheme (CSCS) card, as he previously had joiner
experience.
25. On 8 December, a St Giles Trust worker told Mr McLoughlin that he would be
released to CAS3 accommodation in Keighley. She said that she would support him
to secure permanent accommodation before the end of his stay at the
accommodation.
26. On 9 December, a healthcare administrator referred Mr McLoughlin to Change
Grow Live (CGL - community substance misuse service) in Bradford and made an
appointment for him for continuation of his methadone treatment.
27. On 13 December, a nurse gave Mr McLoughlin his discharge medication, which
included antidepressants and medication for anxiety.
28. On 13 December, Mr McLoughlin was released from HMP Leeds. His licence
conditions required him to report at 1.00pm, to the duty officer at the Bradford
Probation Office.
Post-release
29. On 13 December, Mr McLoughlin reported to a probation officer at the Bradford
Probation Office. Mr McLoughlin completed the induction process and signed the
paperwork. He told her that he felt very anxious because he was in debt to
someone. She and a colleague walked Mr McLoughlin to the railway station and
watched him get onto the train to Keighley.
30. On 14 December, a residential welfare officer telephoned the COM and informed
her that Mr McLoughlin had not arrived at the CAS3 accommodation.
31. On 15 December, Mr McLoughlin telephoned the COM and told her that he had not
been able to get into the accommodation because the key code did not work. She
told Mr McLoughlin to go back to the accommodation and she would give him the
key code over the phone. Mr McLoughlin was able to access the accommodation as
a result. She gave Mr McLoughlin a telephone number to arrange to collect his
prescription medication.
32. On 15 December, Mr McLoughlin did not attend a CRS appointment with the St
Giles Trust worker.
33. On 16 December, Mr McLoughlin did not attend an appointment with the COM at
the Bradford Probation Office. Before the appointment, she telephoned Mr
McLoughlin, who told her that he was on his way. She later telephoned Mr
McLoughlin another five times, but he did not answer her call. She sent Mr
McLoughlin a compliance letter informing him that he had not been recalled to
prison but that he needed to attend his probation appointments.
Prisons and Probation Ombudsman 5
34. On 19 December, an integrated offender manager telephoned the COM and told
her that Mr McLoughlin’s mother had contacted West Yorkshire Police because Mr
McLoughlin had come to her home and asked her for money. This was in breach of
his licence conditions, and the manager said that his behaviour indicated that he
was potentially using illicit drugs. He said that Mr McLoughlin might not be staying
at his CAS3 accommodation, and that the police needed to confirm this with a home
visit.
35. On the same day, Mr McLoughlin saw the COM at the Bradford Probation Office.
She noted that Mr McLoughlin looked okay but had clearly not washed in a while.
She told Mr McLoughlin that he had a ‘fail to attend’ recorded which related to his
failure to attend his planned probation appointment on 16 December. She also said
that he now had a licence condition to keep away from his mother and aunt.
36. Mr McLoughlin told the COM that he had spent the weekend in Ilkley, which she
noted as probably being where he obtained drugs. She noted that Mr McLoughlin
said that he had accumulated £700 of drug debts and that a dealer was “after him”
as a result. There is no record that Mr McLoughlin spoke of being the victim of
violence or of an explicit threat to do him harm.
37. The COM told Mr McLoughlin that his next probation appointment was on 30
December. She gave Mr McLoughlin the bus fare for him to get back to his
accommodation in Keighley.
38. On 20 December, the integrated offender manager told the COM that Mr
McLoughlin had not attended his CGL appointment and had not collected his
prescription.
39. On 21 December, a senior probation officer from the Homeless Prevention Team
asked the COM to contact Mr McLoughlin and explain the importance of attending
appointments. She told the COM that if Mr McLoughlin continued to miss
appointments that his bedspace could be removed in the new year.
40. A residential welfare officer telephoned Mr McLoughlin many times, but he did not
answer his phone.
Circumstances of Mr McLoughlin’s death
41. At about 3.35pm on 21 December, a residential welfare officer went to the CAS3
accommodation with two colleagues to complete Mr McLoughlin’s induction. She
carried out two welfare checks on other residents but did not see Mr McLoughlin.
She went to the basement to top up the energy meter and found Mr McLoughlin
hanged from a beam under the basement staircase.
Post-mortem report
42. The post-mortem report concluded that Mr McLoughlin died from hanging.
43. Toxicology tests showed that Mr McLoughlin had taken a very low level of
methadone in the hours before his death and very low levels of cocaine. Alcohol
was also detected in Mr McLoughlin’s blood, which the consultant histopathologist
said could have been from post-mortem production.
6 Prisons and Probation Ombudsman
Inquest
44. At an inquest held on 2 January 2024, the Coroner concluded that Mr McLoughlin’s
death was suicide.
Contact with Mr McLoughlin’s Family
45. On 21 December, police officers informed Mr McLoughlin’s mother that he had died.
Support for staff
46. After Mr McLoughlin’s death a senior probation officer signposted the COM to
available support services.
Prisons and Probation Ombudsman 7
Findings
47. Mr McLoughlin had some risk factors for suicide and self-harm, most significantly a
drug debt that he indicated was worrying him. He had also been diagnosed with
anxiety and depression and was prescribed medication for this. However, Mr
McLoughlin had no recorded history of having harmed himself in either prison or in
the community and was not managed under ACCT procedures at any time.
48. We are satisfied that there was little to indicate that Mr McLoughlin was at
heightened risk of suicide in the time before his release from prison, or that there
was any specific risk information that should have been shared between prison staff
and his community offender manager or support agencies.
Good practice
49. Mr McLoughlin was referred to several different community services ahead of his
release. This included substance misuse services, support services to help him find
accommodation, for support with his personal wellbeing, and help with finding
employment. When it became apparent that Mr McLoughlin had missed
appointments and was not answering his phone his community offender manager
promptly took steps to locate him.
Adrian Usher
Prisons and Probation Ombudsman November 2023
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