Mitchell, Richard

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Richard Mitchell
on 17 July 2022, following his
release from HMP The Mount
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 Prison 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. Mr Richard Mitchell died of diamorphine intoxication (a heroin overdose) on 17 July
2022, following his release from HMP The Mount on 14 July. He was 46 years old. I
offer my condolences to his family and friends.
4. In October 2020, Mr Mitchell completed a drug detoxification programme while at
The Mount. He engaged with The Forward Trust (a charity that helps people with
drug and alcohol dependency) to address his alcohol misuse.
5. During his pre-release review on 12 July, healthcare staff did not offer Mr Mitchell
naloxone (a medication used to reverse or reduce the effects of opioids) training
and did not arrange an initial appointment with the community substance misuse
service as they should have done.
6. Mr Mitchell was released at the end of his sentence on 14 July. He was not
released on a supervision licence and therefore did not need to engage with the
probation service. There is no recorded evidence that he was offered naloxone
when he left The Mount.
7. Mr Mitchell was released homeless.
8. On the 17 July 2022, a member of the public telephoned the police and told them
that Mr Mitchell, who was behind a derelict community centre in Aylesbury, had
taken heroin and was not breathing. Ambulance paramedics and police officers
attended the community centre and the paramedics confirmed that he had died.
Findings
9. Mr Mitchell should have been trained on the use of naloxone prior to his release
and he should have been offered naloxone on the day of his release, but there is no
recorded evidence that this had happened.
10. The prison’s substance misuse service failed to arrange an initial appointment with
the community substance misuse service for Mr Mitchell prior to his release.
Prisons and Probation Ombudsman 1
Recommendation
• The Head of Healthcare at The Mount, and the Substance Misuse Service lead, should
ensure that healthcare staff:
• encourage prisoners with a history of opioid use to take naloxone kits when they
are released and record the outcome of these discussions in the prisoners’
records.
• arrange initial appointments with community substance misuse services before
prisoners are released.
2 Prisons and Probation Ombudsman
The Investigation Process
11. HMPPS notified us of Mr Michell’s death on 20 July 2022. The PPO investigator
obtained copies of relevant extracts from Mr Mitchell’s prison and probation records.
The investigation was then transferred to one of the investigator’s colleagues.
12. We informed HM Coroner for Buckinghamshire of the investigation. She gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
13. The Ombudsman’s family liaison officer contacted Mr Mitchell’s next of kin, to
explain the investigation and to ask if they had any matters they wanted us to
consider. They did not respond.
14. 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.
Prisons and Probation Ombudsman 3
Background Information
HMP The Mount
15. HMP The Mount is a Category C prison which holds up to 1,028 male prisoners
who have been convicted. GP and primary care health services are delivered by
Practice Plus Group. IAPT (formerly known as talking therapies) mental health
services and substance misuse services are provided by the Forward Trust (a
charity that helps people with drug and alcohol dependency).
Probation Service
16. 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.
4 Prisons and Probation Ombudsman
Key Events
17. On the 16 March 2020, Mr Richard Mitchell was convicted of burglary and
sentenced to 2 years and 4 months in prison. He was sent to HMP The Mount.
18. When he arrived at The Mount, Mr Mitchell completed a methadone detoxification
programme and was supported by the Forward Trust. (He completed the
programme in October 2020.)
19. On 21 September 2020, Mr Mitchell was convicted of common assault and battery
(He committed this offence in January 2020, prior to being sent to prison). He was
sentenced to 2 weeks in prison, which was to run consecutively with his original
sentence.
20. On 30 April 2021, Mr Mitchell was released from The Mount.
21. On 9 June, he was recalled to HMP Bullingdon for assaulting two police officers. He
was sentenced to 4 weeks in prison. Due to being on a standard recall (meaning
that a prisoner stays in prison until the end of their sentence), Mr Mitchell had to
serve the remainder of his original sentence in prison plus the additional 4 weeks to
run consecutively. He would not be released until he sat before the Parole Board.
(The Parole Board is an independent body that carries out risk assessments on
prisoners to determine whether they can be safely released into the community.)
22. On 7 October, Mr Mitchell was transferred to The Mount. He told prison staff that he
wanted to remain in prison custody until his sentence end date, which was on 14
July 2022.
Pre-release planning
23. On the 10 November 2021, Mr Mitchell was allocated a Community Offender
Manager (COM).
24. On 30 November, the COM arranged a telephone call between herself, Mr Mitchell,
and Mr Mitchell’s Prison Offender Manager (POM). They discussed sentence
planning and prepared for his impending parole hearing. During the meeting, Mr
Mitchell said that he wanted to work and that he was on the waiting list. He wanted
support with updating his CV to help him find employment on release. The POM
planned to contact the GP at The Mount and the mental health team as Mr Mitchell
had been on their waiting lists but had not been given an appointment for either. It
was agreed that he would benefit from support from the Forward Trust, and he was
added to their waiting list.
25. In February 2022, the Parole Board decided not to release Mr Mitchell, which meant
that he would serve his entire sentence in prison until 14 July.
26. On the 24 April, Mr Mitchell’s new POM referred him to Accommodation South
Central (a partner agency working with the probation service) through the
Commissioned Rehabilitative Service (CRS - a partnership with the probation
service who support and enable successful rehabilitation), to help secure
accommodation and support on release.
Prisons and Probation Ombudsman 5
27. On 28 April, the POM arranged a teleconference for Mr Mitchell with a worker who
worked for Accommodation South Central. During the call, Mr Mitchell said that he
had already completed a referral to Connection Support (who offer a wide range of
services including homelessness, housing support, and independent living), but he
had not heard anything back. The worker recommended that the COM should
complete 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.)
28. On 13 June, a colleague of the COM completed a duty to refer form and submitted
it to Aylesbury Council. On the 4 July, she followed up her DTR with Aylesbury
Council. A council worker told her that he had been allocated the case and wanted
to do a homelessness assessment on Mr Mitchell prior to his release.
29. On 7 July, a housing officer arranged to complete a homelessness assessment for
Mr Mitchell. The housing officer told Mr Mitchell that he would need to contact the
Housing Department at Aylesbury Council on the day of his release to find out if
they had found accommodation for him and gave Mr Mitchell their telephone
number. We do not know if Mr Mitchell contacted the Council on the day of his
release.
30. The POM made arrangements for a telephone call to take place between Mr
Mitchell and a council worker. The telephone call took place on 8 July. The council
worker gave Mr Mitchell his contact details during the call and told him to call on the
day of his release and provide him with his phone number. We do not know if Mr
Mitchell called the council worker on the day of his release.
31. On 12 July, Mr Michell had a pre-release review. During this review, Mr Mitchell’s
release plans were discussed, he was also provided with the contact details of the
recovery service, One Recovery Bucks (a community substance misuse service).
Mr Mitchell said he had previously engaged with them. The meeting also discussed
harm minimisation, and gave Mr Mitchell substance misuse advice and guidance,
including the risk of low tolerance levels, how to use drugs safely, the dangers of
using illicit substances on top of methadone and the risk of overdosing. Usually
during these pre-release reviews naloxone training is provided to those identified as
suitable. Mr Mitchell should have been provided this training, however it was not
documented that this had been offered to him. Also, during this review, the
practitioner should confirm any referrals made to the community services such as
One Recovery Bucks, however there is no evidence that any referrals were made
for Mr Mitchell prior to his release.
Post-release
32. On 14 July, Mr Mitchell was released from prison. He was not subject to licence
conditions, which meant that he would not be supervised by the Probation Service.
He was not given naloxone.
33. The COM arranged for Mr Mitchell to meet with the CRS team about
accommodation on the day of his release. Mr Mitchell did not attend the
appointment; we do not know why he failed to attend. When Mr Mitchell failed to
attend, the allocated advisor for this appointment contacted the COM, who
confirmed that there was no further probation involvement due to Mr Mitchell being
6 Prisons and Probation Ombudsman
released on his sentence end date. A note was made on the record system that the
CRS intervention would be closed.
34. On 20 July, the CRS team made another appointment for Mr Mitchell. There is no
evidence that Mr Mitchell engaged with any agencies in the time that he was in the
community and before his death.
Circumstances of Mr Mitchell’s death
35. On the 17 July, a member of the public telephoned the ambulance service and told
them that Mr Mitchell, who was behind a derelict community centre in Aylesbury,
had taken heroin and was not breathing. The ambulance service and the police
attended the scene and the paramedics confirmed that Mr Mitchell had died.
Post-mortem report
36. The pathologist gave Mr Mitchell’s cause of death as diamorphine (heroin)
intoxication. Toxicology tests showed that Mr Mitchell had taken cocaine, cannabis,
alcohol, omeprazole (for indigestion and heartburn) and temazepam (to treat sleep
problems).
37. At the inquest held on the 23 January 2023, the coroner concluded that Mr Mitchell
died of drug related causes.
Prisons and Probation Ombudsman 7
Findings
Issues to highlight outside of our remit
42. Mr Mitchell was referred to the local council before his release, under the duty to
refer process. Mr Mitchell’s POM referred him to CRS for help in securing
accommodation, and an appointment was made for him while he was in prison. His
COM made another appointment for him on the day of his release, but Mr Mitchell
did not attend the appointment.
43. Homelessness on release from prison is a significant and complex challenge. Mr
Mitchell had been appropriately referred to his local council prior to release, and
spoke with other partner agencies. We do not know where Mr Mitchell stayed
following his release and we do not know if he called the council on the day of his
release, as instructed.
44. Like many people leaving prison, Mr Mitchell had significant vulnerabilities:
significant substance misuse, and the risk of homelessness. The provision of
suitable and longer-term accommodation for people leaving prison, particularly for
those with complex vulnerabilities, risks and needs, is an issue that extends beyond
the remit of HMP The Mount or local probation services. Housing and communities
and the local authority may want to be aware of the issues raised in this case.
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