Pinkney, Michael

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Michael Pinkney,
a resident at The Crescent
Approved Premises,
on 26 November 2022
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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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.
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.
Mr Michael Pinkney died after overdosing on methadone, an opioid substitute, at The
Crescent Approved Premises on 26 November 2022. He was 39 years old. I offer my
condolences to Mr Pinkney’s family and friends. Mr Pinkney was the first resident to die at
The Crescent in three years.
We found that Mr Pinkney’s risks were generally well managed at the AP. He appeared to
settle in well, complying with rules and engaging positively with staff. There was no
evidence to suggest that AP staff could have foreseen Mr Pinkney’s death and we make
no recommendations.
This version of my report, published on my website, has been amended to remove the
names of staff and residents involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman September 2023
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
Summary
Events
1. On Friday 11 November 2022, Mr Michael Pinkney was released to The Crescent
Approved Premises (AP), after serving 18 months in prison. He had a history of
substance misuse, for which he had engaged with support services in prison.
2. Mr Pinkney settled into the AP well. He engaged with staff and appeared compliant.
He bought and handed in some paracetamol, which he said he used to treat pain
from a historic car accident. He was compliant with his methadone prescription (a
synthetic opioid used to treat heroin dependence) and routine room searches found
nothing inappropriate. Mr Pinkney met a member of the drug strategy team and
talked in detail about his plans for long-term recovery.
3. On 24 November, Mr Pinkney told his offender manager about plans to further his
rehabilitation. He also had a session with his key worker, who completed a drugs
test. The results were negative.
4. On 25 November, Mr Pinkney was out during the day and later went for a walk with
another resident. He returned to the AP at 9.10pm, appearing grey and clammy,
which he put down to the walk and becoming unfit in prison. He went out again and
returned to his room within curfew, chatting to another resident before closing his
door for the night.
5. Staff completed a welfare check at 11.00pm and reported no concerns. At 12.50am,
another resident spoke to Mr Pinkney at his door and raised no concerns. When
staff carried out a welfare check at 6.00am, they found Mr Pinkney lying on the
floor, unresponsive. Staff called an ambulance, but Mr Pinkney could not be revived
and paramedics pronounced his death at 10.15am.
Findings
Assessment and management of risk
6. Since October 2022, mandatory drugs tests are required for all AP residents, at
least twice during their stay. Residents may also be tested if AP staff have a
suspicion that they are using illicit substances. A condition of Mr Pinkney’s licence
was that he should undergo drug testing required by his probation practitioner. This
had not yet been implemented when Mr Pinkney died.
7. When Mr Pinkney arrived at The Crescent, staff were implementing a new process
for drug testing on arrival (as part of the two tests residents were required to
complete during their stay). Due to an oversight, Mr Pinkney was not drug tested on
arrival. However, staff checked him for signs of illicit drug use and did not have any
concerns. In response to the learning, the AP manager issued a notice to staff
reminding them to test residents on arrival.
8. Mr Pinkney was tested for drugs on one occasion in the AP, on 24 November. The
result was negative. The next day, he returned from a walk with another resident
Prisons and Probation Ombudsman 1
and staff noticed he was grey and clammy. When they asked Mr Pinkney about his
presentation he said it was due to walking in the cold weather, his general health
issues and lack of fitness following his time in prison. When we interviewed staff,
they explained there were no obvious signs of illicit substance misuse and they had
no immediate concerns.
9. We are satisfied that staff managed the risks effectively.
2 Prisons and Probation Ombudsman
The Investigation Process
10. We were notified of Mr Pinkney’s death on 28 November 2022.
11. The investigator issued notices to staff and prisoners at The Crescent informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Pinkney’s probation
records. He interviewed three members of staff in April 2023.
13. We informed HM Coroner for Hartlepool of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
14. The Ombudsman’s family liaison officer contacted Mr Pinkney’s mother to explain
the investigation and to ask if she had any matters she wanted us to consider. Mr
Pinkney’s mother had no specific questions.
Prisons and Probation Ombudsman 3
Background
Approved Premises
15. Approved Premises (APs) accommodate offenders released from prison on licence
and those directed to live there by the courts as a condition of bail. Its purpose is to
provide an enhanced level of residential supervision in the community, as well as a
supportive and structured environment. Residents are responsible for their own
healthcare and are expected to register with a GP.
16. The Probation Service manages The Crescent Approved Premises which is based
in Middlesbrough and accommodates up to twelve men. The accommodation is
catered and there is a communal area for eating and socialising. Each resident has
a key worker to oversee their progress and well-being and see that they adhere to
their individual licence conditions and the premises’ rules. AP staff are on duty 24
hours a day. During the night, staff only check on residents if there is a specific
need to do so (such as a resident at risk of self-harm being under procedures to
support them, or a resident with a medical issue that requires night-time care).
Previous deaths at The Crescent
17. There were no other deaths at The Crescent in the three years before Mr Pinkney
died.
4 Prisons and Probation Ombudsman
Key Events
18. Mr Michael Pinkney was remanded to HMP Durham in April 2020, charged with
robbery. It was not his first time in custody. In November, Mr Pinkney was
sentenced to five years and two months imprisonment.
19. In December 2020 Mr Pinkney transferred to HMP Holme House. Staff identified
that Mr Pinkney had a history of mental ill-health, for which he was prescribed
medications. They also identified long standing substance misuse issues and made
a referral to the substance misuse service to support Mr Pinkney’s withdrawal. Mr
Pinkney engaged with mental health and substance misuse services while at Holme
House. Staff did not record any concerns, other than Mr Pinkney’s concerns about
being released homeless.
20. On Friday 11 November 2022, Mr Pinkney was released from Holme House with a
licence condition that he should reside at The Crescent Approved Premises (AP).
He had a curfew which meant he must be in the AP between 11.00pm and 6.00am
and would need to report to AP staff at midday.
21. Mr Pinkney received an induction briefing on arrival, which included information on
AP rules and support available to residents. He handed in his antidepressant
medication, as required by AP policy.
22. On 12 November, staff recorded that Mr Pinkney had settled into the AP. He went
out and visited a friend, then went to the pharmacy for his prescription of
methadone (a synthetic opioid used to treat heroin dependence). Mr Pinkney was
on a supervised prescription of methadone, which meant that he went to the
pharmacy daily and would be given his dosage in view of the pharmacist. 12
November was a Saturday and the pharmacy would be closed the following day, so
after taking his daily dosage they gave Mr Pinkney the following day’s dosage. He
returned to the AP and handed it in to staff. He said that he felt well and had no
concerns.
23. On 13 November, Mr Pinkney went out to local shops. When he returned, in line
with the policy on medication, he handed in some paracetamol that he had bought
and asked for two tablets. He told staff that he experienced pain from injuries
sustained in a car accident before he was in prison, as well as other health issues,
but was careful about the type of pain medication he used because of his problems
with substance misuse. He took his antidepressants and went to his room.
24. The following day, staff conducted their routine weekly search of all residents’
rooms and found nothing of concern in Mr Pinkney’s. Mr Pinkney and another
resident went out, and on return he asked for two paracetamol and his medication
before retiring to his room. On 15 November, apart from going to the pharmacy for
his methadone, he remained in the AP and no concerns were raised.
25. On 16 November, Mr Pinkney met a member of the regional AP drug strategy team
to provide some input into the drug strategy and intervention pack that they were
creating. He talked of his long-term plans for his recovery and said he would be
speaking to his doctor about reducing his methadone prescription. It was his hope
to become a drugs worker through a peer mentor programme when he had reached
Prisons and Probation Ombudsman 5
the appropriate stage of his recovery. He said that he was considering moving to an
AP near Liverpool that had a good recovery and rehabilitation structure. She said
she would obtain further information on the AP for Mr Pinkney. He later went to the
pharmacy for his medication and attended an appointment at the Job Centre. He
complied with his curfew and collected and took his medication.
26. Mr Pinkney was due to see his probation practitioner on 17 November but did not
attend. Given that he had engaged with staff up to this point, she accepted that this
was an error. She rescheduled the appointment for 24 November.
27. On 18 November, Mr Pinkney had a meeting with his probation key worker (a
named member of staff to engage with each resident and provide a responsive
service, reflecting individual needs). Mr Pinkney said that he found some days
emotionally difficult and that his mental health had been “up and down”. He
speculated that this might also have been affected by some ongoing health
concerns and a knee operation he was due to have. Mr Pinkney had no fixed plans
for when he left the AP, though he said he would like to go to a residential
rehabilitation facility. He was unsure of how to go about this. In the short-term he
planned to find somewhere close to his family.
28. At midday, Mr Pinkney telephoned the AP. He said that he knew he was supposed
to report to staff but was in a queue in the medical centre. Staff spoke to the
centre’s receptionist who confirmed that he was waiting in long a queue. When Mr
Pinkney returned, he asked for two paracetamol and then talked with other
residents before closing his door.
29. On 19 November, Mr Pinkney handed in his medication and prescriptions for the
next two weeks to one of the AP’s residential workers. Mr Pinkney took his daily
medication and asked for paracetamol.
30. On 21 November, the probation practitioner discussed Mr Pinkney with her
manager. AP staff had given positive feedback about Mr Pinkney’s attitude to
addressing his substance misuse issues. The routine weekly room search found
nothing of concern.
31. On 24 November, Mr Pinkney had a meeting with his probation practitioner. He told
her that he had a number of medical problems stemming from injuries sustained in
a traffic accident in 2016. He still wanted to move to a rehabilitation centre near
Liverpool but would need funding. He would also need to reduce his current
methadone prescription. Mr Pinkney also had a key work session with his probation
key worker. He talked about his medical issues and said that he had a doctor’s
appointment to discuss these. He confirmed his long-term plan to enter a
rehabilitation centre. His probation keyworker completed a routine drug test, the
results of which were negative.
32. On 25 November, Mr Pinkney complied with his curfew, but was otherwise out
during the day. He attended the Job Centre with a fellow resident, and later went for
a walk with another resident. He returned to the AP at 9.10pm. An AP residential
worker gave him his medication and noted that he appeared grey and clammy and
had trouble getting the medication out of the packet. He told her that he had been
walking and that he had lost fitness in prison. Just before 9.50pm, he went out
again. Another resident seemed keen for Mr Pinkney to return, watching out of the
6 Prisons and Probation Ombudsman
window for him. In interview, the residential worker said that unlike Mr Pinkney, this
resident did not know the local area, and she thought that he was waiting to ask Mr
Pinkney about his local knowledge. Mr Pinkney returned to the AP at 10.30pm. Staff
had no concerns about him.
33. Staff made a welfare check on residents at 11.00pm. At 12.50am the AP residential
worker was monitoring the AP’s CCTV system and saw the resident from the
neighbouring room go to Mr Pinkney’s room and speak to him at the door. She was
about to go and tell them to settle down when the other resident went back to his
room and they each closed their doors. Over the course of the night, Mr Pinkney did
not leave his room and staff did not record any concerns overnight. (Mr Pinkney
was not subject to any night checks.)
34. At 6.00am on 26 November, staff carried out their usual welfare checks on
residents. A residential worker arrived at Mr Pinkney’s room and found him lying on
the floor. He used his radio to call for a colleague, who arrived moments later and
tried to get a response from Mr Pinkney but could not do so. They could see what
appeared to be a needle in his leg. Mr Pinkney was not breathing, had no pulse,
and showed no signs of life. The colleague called 999 and described the situation to
the operator, who said that any attempt to revive Mr Pinkney would be futile, and
they would notify the police. A paramedic later attended and at 10.15am officially
pronounced that Mr Pinkney had died.
Contact with Mr Pinkney’s family
35. The police contacted Mr Pinkney’s family and informed them of his death. AP staff
followed up and made their own contact with Mr Pinkney’s family.
36. The Probation Service contributed to the cost of Mr Pinkney’s funeral, in line with
national policy.
Support for residents and staff
37. After Mr Pinkney’s death, the AP manager debriefed staff to ensure they had the
opportunity to discuss any issues arising, and to offer support.
38. AP staff spoke to residents in case they had been adversely affected by Mr
Pinkney’s death.
Post-mortem report
39. The post-mortem report showed that Mr Pinkney died of methadone toxicity. There
was evidence of alcohol and cocaine in Mr Pinkney’s system.
Prisons and Probation Ombudsman 7
Findings
40. Mr Pinkney engaged well with staff and AP rules throughout his time at The
Crescent. Staff provided a good standard of support overall.
Assessment and management of risk
41. Post-mortem tests showed that Mr Pinkney died of methadone toxicity. There were
also traces of alcohol and cocaine in his system. Mr Pinkney had longstanding
substance misuse issues for which he was prescribed methadone (a synthetic
opioid used to treat heroin dependence) in prison. Mr Pinkney was provided with
continuity of his methadone prescription on release and had plans to reduce his
prescription. He was open about his issues with staff and talked about his plans for
recovery in detail, including a rehabilitation centre he was interested in joining.
There were no obvious issues surrounding his compliance with his methadone
prescription, which he was required to collect and administer with oversight from a
pharmacist.
42. In October 2022, mandatory drugs tests were rolled out nationally for AP residents.
Two tests are now required during a resident’s stay. The Crescent was part way
through the implementation of a new process for drugs testing on arrival when Mr
Pinkney arrived. They did not test him, due to an oversight, but did check for signs
of illicit substance misuse and found no concerns. In response to the learning from
Mr Pinkney’s death, the AP manager quickly issued a notice to staff, reminding
them to test residents on arrival.
43. AP residents may also be tested on suspicion of illicit substance misuse. Routine
engagement and room checks did not find any signs of substance misuse so no
drugs tests were completed on the basis of suspicion for Mr Pinkney. He was given
a random drug test on one occasion, on 24 November, for which the result was
negative.
44. The next day, Mr Pinkney returned from a walk with another resident and appeared
grey and clammy. A residential worker asked him if he was okay, and he said that
he had been walking on a cold night, had become unfit in prison, and had a number
of health issues. She said in interview that this appeared consistent with his
appearance, and he showed no common signs of drug use such as slurring his
words, being unsteady on his feet, or having changes to the appearance of his eyes
in a way associated with drug use. She had no suspicion that he was under the
influence of drugs.
45. Mr Pinkney’s licence conditions included compliance with drug testing required by
his probation practitioner. When Mr Pinkney died, these were yet to be scheduled.
46. We found no evidence that staff missed signs that Mr Pinkney’s risk of substance
misuse had increased. The failure to test Mr Pinkney on arrival was an isolated
oversight that was quickly identified and addressed and we found no suggestion
that this was a systemic issue, or that it had any bearing on his death. We do not
make any recommendations.
8 Prisons and Probation Ombudsman
Inquest
47. The inquest, held on 17 April 2024, concluded that Mr Pinkney died after taking an
unintentional overdose of both prescribed and non-prescribed medication.
Prisons and Probation Ombudsman 9
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