Wilton, Thomas

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Thomas Wilton,
on 4 November 2021, following
his release from HMP Preston
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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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. From 6 September 2021, the PPO also investigates post-release deaths that occur
within 14 days of the prisoner’s release.
3. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
4. Mr Thomas Wilton died of hypothermia in the context of multiple drug toxicity on 3
November 2021, in a street in Burnley, following his release from HMP Preston six
days earlier. He was 29 years old. We offer our condolences to Mr Wilton’s family
and friends.
5. The clinical reviewer concluded that the clinical care that Mr Wilton received at
Preston was equivalent to that which he could have expected to receive in the
community.
6. The clinical reviewer made one recommendation about the local prison procedures
for missed GP appointments, which we do not repeat in this report but which the
Head of Healthcare will need to address.
7. We found an issue of concern relating to record keeping. Probation staff failed to
keep Mr Wilton’s probation record on nDelius (the Probation case management
system) updated. As a result, some of the actions undertaken by probation staff in
preparation for Mr Wilton’s release were not evidenced.
Recommendation
• The Head of East Lancashire Probation Delivery Unit should ensure that COMs
record all contact and actions completed on individual cases on nDelius (the
Probation Service’s case management system).
Learning to highlight outside our remit
8. Mr Wilton was released from prison homeless, and without even temporary
emergency accommodation in place. The provision of suitable accommodation for
people leaving prison is challenging and is an issue that extends beyond the remit
of HMP Preston or local probation services. The local authority will want to be
aware of the issues raised in this case.
Prisons and Probation Ombudsman 1
The Investigation Process
9. The PPO investigator obtained copies of relevant extracts from Mr Wilton’s prison
and probation records.
10. NHS England commissioned a clinical reviewer to review Mr Wilton’s clinical care at
the prison. The investigator interviewed one Community Offender Manager on 14
December 2021. The investigator and clinical reviewer jointly interviewed two
members of staff on 20 December 2021.
11. We informed HM Coroner for Lancashire and Blackburn with Darwen of the
investigation. The investigation was suspended from 18 January to 8 February 2022
as we waited for the post-mortem and toxicology results. We have sent the coroner
a copy of this report.
12. The Ombudsman’s family liaison officer contacted Mr Wilton’s family to explain the
investigation and to ask if they had any matters they wanted the investigation to
consider. They did not respond.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
2 Prisons and Probation Ombudsman
Background Information
HMP Preston
14. HMP Preston operates as a category B male local and resettlement prison,
servicing courts across northwest England. The prison holds males aged 18 and
over remanded in custody awaiting trial, serving sentences of 12 months or less, or
awaiting transfer to another prison after sentencing.
Probation Service
15. The Probation Service works 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. They
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.
Prisons and Probation Ombudsman 3
Key Events
16. On 4 December 2020, Mr Thomas Wilton was sentenced to 22 weeks in prison for
theft, possession of cannabis, criminal damage, assault, obstruction,
racially/religious aggravated fear and provocation of violence. He was sent to HMP
Lancaster Farms. This was not his first time in prison.
17. Mr Wilton was released from Lancaster Farms on 29 January 2021, but on 13
September, he was arrested for further offences and recalled to HMP Preston. He
was due to be released a little over a month later on 29 October 2021.
18. On reception at the prison, Mr Wilton had an initial health screen. Nursing staff
assessed him and identified that he had a history of anxiety and depression, illicit
drug misuse and excessive alcohol use. Mr Wilton told staff that he had a history of
self-harm and taking overdoses. A urine test was positive for cocaine, opiates (a
class of drugs that include the illegal drug heroin) and benzodiazepines (sedative
medication which can be prescribed to induce a relaxed state). A clinical
assessment for alcohol withdrawal scored Mr Wilton in the moderate range of 13.
An alcohol screen scored him in the very high range of 27 indicating the likelihood
of alcohol dependence (moderate-severe alcohol use disorder). Mr Wilton said that
he used drugs daily. He had a COVID-19 test and the result was negative.
Healthcare staff commenced him on a nine-day alcohol detoxification programme.
19. The next day, 14 September, a nurse completed a secondary reception screen. Mr
Wilton described his drug use as crack cocaine, alcohol and cannabis. She noted
that he had been prescribed antidepressants in January 2020 at a previous prison,
but that he was not currently on any prescribed medication. Healthcare staff
referred him to the Mental Health Team and Substance Misuse Service (SMS).
20. Mr Wilton missed two GP appointments and the prison GP left a message for him to
reschedule another appointment, but he never did. Healthcare staff did not follow
this up further as they should have done.
Pre-release planning
21. On 8 September, Mr Wilton was allocated a Community Offender Manager (COM).
She arranged to meet Mr Wilton in October before his release from prison later that
month and shortly after his release to discuss his resettlement plans when he left
prison. She completed a ‘duty to refer’ form to the local council for his housing
needs. A ‘duty to refer’ form is completed when there is reason to believe that a
person will be homeless or is threatened with becoming homeless, in accordance
with the Homelessness Reduction Act 2017.
22. On 15 September, a Support Recovery Worker, and part of Spectrum Healthcare’s
drug and alcohol services, met Mr Wilton. Their discussion focused on his alcohol,
crack cocaine and cannabis use. She referred Mr Wilton to Burnley Inspire drug and
alcohol services in the community for further support on his release.
23. On 17 September, Mr Wilton was appointed a drug and alcohol practitioner. On 7
October, she completed a comprehensive assessment and confirmed that staff had
made a referral to Burnley Inspire drug and alcohol services for continued support
4 Prisons and Probation Ombudsman
in the community. On 21 October, Mr Wilton attended a psychosocial group session
with the Drug and Alcohol Services (DARS).
24. Being released 'on licence' means that for the rest of their sentence the released
prisoner must adhere to certain conditions in the community and will be supervised
by the Probation Service. As Mr Wilton’s release date was approaching, staff began
to prepare his release licence. The licence noted that Mr Wilton’s post sentence
supervision started on 29 October 2021 and expired on 29 January 2022. He was
required to report to the Burnley Probation Office at 1.30pm on 29 October.
25. On 28 October, staff told Mr Wilton that on the day of his release, he had to report
to Burnley Inspire at 2.00pm. His drug and alcohol practitioner also discussed
overdose awareness, harm reduction and tolerance levels with him. The practitioner
did not consider providing Mr Wilton with naloxone (a medication that can reverse
the effects of opioids) because he was not prescribed methadone.
26. In interview, the COM said that she rearranged her appointment with Mr Wilton to 1
November and also completed a referral to New Beginnings (a charity that provides
accommodation for people with alcohol and drug issues). She said that she
received a notification confirming that his application was being processed.
27. From July 2021, the Community Accommodation Service Tier 3 (referred to as
CAS3) was introduced as a project to provide temporary accommodation for up to
84 nights for homeless prison leavers to help them move into settled
accommodation.
28. The COM told us that she could not find any notes detailing whether she had
considered referring Mr Wilton to CAS3, which left her to surmise that at that time,
CAS3 was not easily accessible. She said that there had to be confirmation from
the local authority that they were not able to offer accommodation and proof that all
other options had been fully explored. She said she was unable to provide this
evidence within the short time frame and concluded that CAS3 accommodation was
not a viable option at the time of Mr Wilton’s release.
29. The COM said that she had made a referral to accommodation support services
(New Beginnings). However, due to staff shortages, referrals were delayed. She
said that after her conversations with Mr Wilton in prison, she had intended to
discuss this further at their meeting at the probation office. Mr Wilton died before
this could happen.
30. On Friday 29 October 2021, Mr Wilton was released from Preston. He was
homeless.
Post-release
31. Mr Wilton attended his Burnley Inspire appointment on the day of his release and
attended his induction with his COM on 1 November. Mr Wilton said that he had
stayed with family over the weekend but had no fixed place to live.
Prisons and Probation Ombudsman 5
Circumstances of Mr Wilton’s death
32. On 3 November 2021, a member of the public found Mr Wilton dead on a grassy
area near a housing estate. The police identified him through his fingerprints.
Post-mortem report
33. The post-mortem report concluded that Mr Wilton died of hypothermia in the context
of multiple drug toxicity (opiates, cocaine, benzodiazepines, pregabalin, mirtazapine
and alcohol).
6 Prisons and Probation Ombudsman
Findings
Substance misuse
34. Mr Wilton had a significant history of substance misuse, and his offending was
linked to his substance misuse. His sentences reflected a cycle of offending, short
prison sentences and community supervision.
35. When Mr Wilton arrived at HMP Preston, nursing staff identified that he had drug
and alcohol issues and appropriately referred him for support.
36. We are satisfied that there was appropriate planning for Mr Wilton’s release and
that the relevant referrals were made to services that could support him. He was
also referred to a community substance misuse service and he attended an
appointment with them on the day of his release.
37. Mr Wilton was not provided with naloxone on his release from prison because he
was not prescribed methadone in prison and had received support around his use
of crack cocaine and cannabis, rather than opiates. Staff did not consider him to be
at high risk of an opiates overdose. We consider that, in the circumstances, this was
not unreasonable.
Accommodation
38. Homelessness on release from custody is a significant and complex challenge,
particularly over a weekend. Mr Wilton was only in prison for one month, was
released from prison on a Friday and spent his first weekend homeless and sofa
surfing in the community. His death highlights the importance of staff making
prompt referrals and chasing them up to avoid periods of homelessness after
release.
39. CAS3 was rolled out in East Lancashire on 10 September 2021. The East
Lancashire Homelessness Prevention Team told us that at that time there was very
limited availability and probation practitioners were advised of this, and it was
unlikely that Mr Wilton would have been accommodated. We understand that in the
circumstances Mr Wilton was reliant upon accommodation being provided by the
local authority or the charitable accommodation services.
40. We note that at the time of his release, there were no arrangements in place for
suitable temporary or permanent housing. However, we consider that the COM
acted appropriately as an appropriate accommodation referral was made in line with
policy and process. We understand from the area Homelessness Prevention Team
that further training for practitioners is being rolled out in relation to referrals and
assessing eligibility for bed spaces to support the scheme.
41. We accept that any referrals would not have been progressed over the weekend.
We would have expected the COM to have chased up this referral the next week,
and to have possibly made further accommodation referrals, if necessary, but in the
event, Mr Wilton died two days after meeting with her.
Prisons and Probation Ombudsman 7
42. Being released on a Friday also meant that Mr Wilton had very limited time to
access accommodation support from external organisations before the weekend,
should he have wanted to do so. In June 2022, the Ministry of Justice announced
that as part of a package of prison reforms, it wanted to introduce measures to
allow prisoners to be released one or two days early to avoid releasing them on a
Friday. We welcome this initiative.
Quality of record keeping
43. Despite the COM telling the investigator that she had met Mr Wilton at prison, made
referrals to source accommodation for him and completed an induction
appointment, there is no evidence of this on nDelius. We recommend:
The Head of East Lancashire Probation Delivery Unit should ensure that
COMs record all contact and actions completed on individual cases on
nDelius (the Probation Service’s case management system).
Susannah Eagle
Deputy Ombudsman April 2023
Inquest
The inquest, heard on 5 April 2024, concluded that Mr Wilton’s death was drug related.
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