Stacey, Neal

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Neal Stacey
on 20 May 2023, 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. 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 Neal Stacey died from combined drug and alcohol toxicity on 20 May 2023
following his release from HMP Lewes on 17 May. He was 56 years old. I offer my
condolences to those who knew him.
5. We found that Mr Stacey received satisfactory support with his substance misuse
issues at Lewes. Substance misuse support was also put in place for when he was
released from prison.
6. Mr Stacey was released homeless. However, we found that Mr Stacey’s community
offender manager had made the appropriate accommodation referrals to local
authorities and homelessness support services. Also, part of the reason that Mr
Stacey was released homeless was because he did not wish to return to his home
area of Portsmouth and instead chose to go to Southampton, an area which had no
duty to house him.
7. We make no recommendations.
Prisons and Probation Ombudsman 1
The Investigation Process
8. HMPPS notified us of Mr Stacey’s death on 14 August 2023.
9. The PPO investigator obtained copies of relevant extracts from Mr Stacey’s prison
and probation records.
10. We informed HM Coroner for East London of the investigation. They gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
11. The Ombudsman’s family liaison officer contacted Mr Stacey’s next of kin, his
brother, to explain the investigation and to ask if he had any matters he wanted us
to consider. He did not respond.
12. We shared our initial report with HMPPS. They pointed out some minor factual
inaccuracies which have been amended in this report.
2 Prisons and Probation Ombudsman
Background Information
HMP Lewes
13. HMP Lewes is a local prison serving the courts of East and West Sussex, holding
up to 624 men. Practice Plus Group (PPG) provides primary care services and
healthcare staff are on duty 24-hours a day. PPG also provides substance misuse
services.
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.
HM Inspectorate of Prisons
15. The most recent unannounced inspection of HMP Lewes was in June 2022.
Inspectors reported that prisoners arriving at the establishment received a thorough
screening and those who were drug and/or alcohol dependent were housed on the
stabilisation unit and received additional monitoring and access to first night
prescribing, which was flexible and reflected individual need. Inspectors reported
that clinical and psychosocial teams worked collaboratively to offer harm
minimisation advice, deliver individual support, and complete regular joint reviews.
Discharge planning was effective, with good links to local community services.
Naloxone training (to reverse the effects of opiates) and general service information
was provided before release.
16. The demand for resettlement help was high, with an average of nearly 100
prisoners being released each month. Many prisoners leaving the establishment
had been there for only a very short time, which added to the challenges of timely
and effective release planning. The pre-release team had however developed
comprehensive discharge packs, offering a range of useful information, tailored
according to prisoners’ release areas. Accommodation in the local area was
provided as part of the Community Accommodation Service Tier 3 pilot programme
to reduce homelessness among prison leavers; this was a good initiative and had
provided valuable help for some since its inception. Despite this, prison data
showed that only about 65% of sentenced prisoners left with accommodation to go
to on their first night of release.
HM Inspectorate of Probation
17. The most recent inspection of the Portsmouth and the Isle of Wight Probation
Delivery Unit (PDU) was in July 2023. Inspectors rated the PDU as ‘requiring
improvement’. High staff vacancies meant that caseloads were not manageable and
although inspectors saw some positive aspects of practice, they noted that more
was needed to ensure that a sufficient quality of work was being undertaken with
Prisons and Probation Ombudsman 3
people on probation. Inspectors found a suitable range of commissioned
rehabilitative service (CRS) provision, however that staff were not always utilising
what was available to them and referrals into partnerships were not at the expected
level.
4 Prisons and Probation Ombudsman
Key Events
18. On 11 January 2023, Mr Neal Stacey was remanded to HMP Bullingdon.
19. On 1 March, Mr Stacey was convicted of breaching his restraining order and
sentenced to 12 weeks imprisonment. He was moved to HMP Lewes. As he was
also on recall for a previous offence, he remained in prison after the release date for
this offence.
Pre-release planning
20. On 3 March, a substance misuse recovery worker saw Mr Stacey for an initial
assessment. Mr Stacey said that he had not used drugs for approximately two
years, but that he drank alcohol daily in the community. Mr Stacey had already
completed an alcohol detoxification programme at Bullingdon. Mr Stacey told the
recovery worker that he did not have a release address and planned to move to
Southampton. As a result, the recovery worker sent a referral to the local substance
misuse service in Southampton.
21. On 14 March, Mr Stacey’s prison offender manager (POM) saw him for his initial
appointment. Mr Stacey told his POM that prior to his recall he was living homeless
on the streets of Portsmouth, and that he would like to be released to Southampton.
He said that he would like to be away from negative peers in Portsmouth who he
said caused him to reoffend.
22. The same day, the POM sent an email to the resettlement team at Lewes asking
them to complete an urgent housing referral to Southampton City Council (there is
no evidence that the referral was made).
23. On 27 March, a member of the resettlement team saw Mr Stacey for a follow up
appointment. He asked Mr Stacey where he would like to be released to. Mr Stacey
said he did not want to be released to Portsmouth, so the resettlement worker
completed a duty to refer application (DTR, where certain public authorities must
notify local authorities that a person who has engaged with them might be homeless
or at risk of homelessness) to a neighbouring borough council, Havant.
24. On 27 April, as no accommodation had yet been found for Mr Stacey, his
community offender manager (COM) completed a DTR application to Portsmouth
City Council and a housing referral to the local commissioned rehabilitative service
(CRS), Ingeus. The COM told the POM that it was unlikely that any council other
than Portsmouth would house Mr Stacey, as they were the council that held the
duty (because he had been living there before coming to prison).
25. On 5 May, the POM saw Mr Stacey to discuss his release accommodation. Mr
Stacey told the POM that he wanted to be released to Southampton. The POM
explained that it was unlikely that Southampton City Council would house him as
they did not hold the duty. Despite this, Mr Stacey said that he would rather be
released to Southampton and be homeless than return to Portsmouth.
26. On 13 May, Mr Stacey had an accommodation appointment with Ingeus at 3.00pm.
He did not attend, so Ingeus rebooked the appointment for a later date (as Mr
Prisons and Probation Ombudsman 5
Stacey was released and then died a few days later, this appointment did not take
place).
Post-release
27. On 17 May at approximately 9.30am, Mr Stacey was released from Lewes. As Mr
Stacey planned to go to Southampton, his COM arranged for him to be seen by a
probation practitioner at the Southampton Probation Office at 2.00pm.
28. The same day at 5.00pm, Mr Stacey attended Southampton Probation Office. The
duty probation practitioner noted that Mr Stacey appeared to be intoxicated and that
he became rude and aggressive when he was questioned about arriving three
hours late. The probation practitioner issued him with a mobile phone and told him
to come back the next day at 10.30am.
29. The next day at 11.45am, Mr Stacey attended Southampton Probation Office and
again appeared to be under the influence of alcohol. He became abusive to staff
and was told to leave the premises. Due to Mr Stacey’s poor behaviour, the COM
started breach paperwork.
30. On 19 May at 8.45am, Mr Stacey went to Southampton Probation Office. As he did
not have an appointment, the duty probation practitioner saw him and advised him
to get in contact with his COM. He then gave Mr Stacey a map to get to the local
homeless day centre.
31. Later that day, the COM phoned Mr Stacey. My Stacey apologised for his behaviour
and told the COM he was going to travel to London that evening where he had
friends that he could stay with. Mr Stacey told the COM that he would confirm the
address when he arrived.
32. The COM did not receive a phone call from Mr Stacey on Monday 22 May as had
been agreed on 19 May. Attempts were made to contact Mr Stacey but these were
unsuccessful.
Circumstances of Mr Stacey’s death
33. On 20 May, Mr Stacey was at an address in Walthamstow, London, when he
collapsed. The emergency services attended and started resuscitation attempts. He
was taken to a local hospital where he was pronounced dead.
34. Since he was not informed of his death in May, the COM made numerous attempts
to contact Mr Stacey via telephone. He also contacted the police and other
agencies working with Mr Stacey, but nobody knew of his whereabouts.
35. On 7 August, Portsmouth court team informed the COM that Mr Stacey had died.
Post-mortem report
36. The post-mortem report concluded that Mr Stacey died of respiratory failure due to
combined drug and alcohol use. The pathologist noted that the most significant
findings from the toxicology report was the detection of high levels of cocaine and
6 Prisons and Probation Ombudsman
alcohol. He also noted that several opiate based drugs were detected and although
these were at therapeutic levels, it is likely that the combination of these with the
cocaine and alcohol would have caused respiratory failure. Heart disease, chronic
obstructive pulmonary disease (COPD, lung disease), hepatitis C and liver cirrhosis
were contributing factors.
Findings
Substance misuse
37. Mr Stacey had a history of substance misuse. While he was at Lewes, he was seen
by the substance misuse team and allocated a recovery worker. Prior to his release,
the recovery worker sent a referral to a local Southampton substance misuse
service to ensure he could access SMS support in the community.
38. We are satisfied that Mr Stacey’s COM put appropriate measures in place to
address his substance misuse issues when he was released from prison. This
included adding licence conditions to comply with any requirements relating to
addressing his substance misuse issues.
Accommodation
39. Homelessness on release from prison is a significant and complex challenge. While
prison and probation staff can submit referrals to local authorities and charities,
there are occasions when beds are not available, or the individual does not meet
the eligibility criteria for housing. This means that these individuals are released
homeless and are expected to report to the local authority on the day of their
release in the hope of receiving emergency housing. If an individual is homeless, it
can increase the likelihood that they will commit further crimes or seek shelter and
support in harmful places.
40. Mr Stacey was released from prison without any suitable accommodation. However,
we consider that Mr Stacey’s COM suitably prepared for his release by promptly
completing accommodation referrals to the local authorities and arranging for him to
be seen by Southampton probation when he decided to relocate there.
41. The provision of suitable accommodation for people leaving prison is an issue that
extends beyond the remit of HMP Lewes or local probation services.
Adrian Usher
Prisons and Probation Ombudsman January 2024
Inquest
The inquest, held on 28 March 2024, concluded that Mr Stacey’s death was drug and
alcohol related.
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