McAllister, Addy

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Addy McAllister,
a prisoner at Burdett Lodge
Approved Premises, on 6 July
2020
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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
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 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.
Mr Addy McAllister died at Burdett Lodge Approved Premises on 6 July 2020 of combined
drug toxicity. He was 38 years old. I offer my condolences to Mr McAllister’s family and
friends.
While in prison, Mr McAllister had successfully stopped taking drugs, and there was no
evidence to indicate that he had recently used drugs in prison. I am satisfied that staff at
Burdett Lodge had no reason to suspect that Mr McAllister was taking illicit drugs.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman February 2024
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
Summary
Events
1. In 2017, Mr Addy McAllister was convicted of manslaughter and sentenced eight
years in prison. He had no significant health issues, was not prescribed any
medication and had no history of self-harm. He had a history of substance misuse
but he had successfully stopped taking drugs while in prison at HMP Lindholme and
there is no evidence that he had used drugs in prison in the eleven months before
his release.
2. On 11 May 2020, Mr McAllister was released on licence from Lindholme to Burdett
Lodge Approved Premises (AP). A residential support worker completed Mr
McAllister’s induction and made him aware of a reduced tolerance to drugs and an
increased risk of overdose after release from prison.
3. Mr McAllister had regular contact with his probation practitioner who noted that he
was feeling stronger and intended to remain drug-free. Mr McAllister complied with
his curfew and AP staff did not suspect that he was under the influence of illicit
substances.
4. At 6.00am on 6 July, a night support worker carried out a welfare check of residents
and reported that Mr McAllister was asleep in bed. At 9.40am a resident alerted
staff that Mr McAllister was unresponsive in his room. Staff immediately attended
and a residential worker used her mobile phone to call an ambulance. The AP
manager started cardiopulmonary resuscitation (CPR). At 9.51am, paramedics
arrived and took over Mr McAllister’s care. At 10.41am, a paramedic confirmed that
Mr McAllister had died.
5. A post-mortem examination found that Mr McAllister died of mixed drug toxicity and
bronchopneumonia.
Findings
6. Mr McAllister appeared to have been determined to change his lifestyle, including
abstaining from drug use, on his release from Lindholme. AP staff told him about his
likely reduced tolerance to drugs and his increased risk of overdose when he
arrived.
7. Drug testing at Burdett Lodge had been suspended at the time of Mr McAllister’s
death due to COVID-19. AP staff said that Mr McAllister did not present as being
under the influence of drugs at any time while he was resident at Burdett Lodge. In
the hours before his death, staff did not have any concerns about his behaviour. We
are satisfied that staff had no reason to suspect that he might be using illicit drugs.
Prisons and Probation Ombudsman 1
The Investigation Process
8. HMPPS notified us of Mr McAllister’s death on 7 July 2020.
9. The investigator issued notices to staff and prisoners at Burdett Lodge Approved
Premises informing them of the investigation and asking anyone with relevant
information to contact her. No one responded.
10. The investigator obtained copies of relevant extracts from Mr McAllister’s prison and
medical records. She spoke to the AP manager and Mr McAllister’s AP key worker
several times by videoconferencing.
11. The case was suspended while we waited for the cause of death.
12. We informed HM Coroner for Derby and South Derbyshire of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
13. We wrote to Mr McAllister’s mother to explain the investigation and to ask if she had
any matters she wanted us to consider. Mr McAllister’s mother asked if Mr
McAllister was routinely drug tested and about the events leading up to his death.
We have answered her questions in the report.
14. Mr McAllister’s mother received a copy of the initial report. She pointed out a factual
inaccuracy. This report has been amended accordingly, and also addressed in
separate correspondence.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
2 Prisons and Probation Ombudsman
Background Information
Burdett Lodge
16. Approved premises (formerly known as probation or bail hostels) accommodate
offenders released from prison on licence and those directed to live there by the
courts as a condition of bail. Their purpose is to provide an enhanced level of
residential supervision in the community, as well as a supportive and structured
environment.
17. The National Probation Service manages Burdett Lodge Approved Premises (AP) in
Derby. It has 29 bedrooms and there is a kitchen and dining area that the residents
can use. A key worker is allocated to each resident to oversee their progress,
wellbeing and adherence to licence conditions and the premises’ rules. Probation
Service employees are on duty 24 hours a day to monitor residents' behaviour and
report to their offender manager.
Previous deaths at Burdett Lodge
18. Mr McAllister was the second resident to die at Burdett Lodge since July 2017.
There were no similarities with the previous investigation.
Parole Board
19. The Parole Board for England and Wales is an independent public body. Its role is
to make risk assessments about prisoners to decide whether they can safely be
released into the community once they have served the minimum term of
imprisonment imposed by the courts.
Prisons and Probation Ombudsman 3
Key Events
20. On 24 September 2015, Mr Addy McAllister was sentenced to life in prison for
murder and sent to HMP Woodhill. On 25 September 2017, Mr McAllister was
sentenced to 8 years in prison for manslaughter after he appealed against his
original conviction. He spent time in several prisons before moving to HMP Ranby
on 23 August 2018.
21. On 25 March 2019, Mr McAllister was released on licence to an Approved Premises
(AP) but was recalled to HMP Lincoln on 9 April after he received a warning for
taking psychoactive substances.
22. Mr McAllister had a history of substance misuse but completed a methadone
detoxification programme in prison.
HMP Lindholme
23. On 25 April 2019, Mr McAllister was transferred to HMP Lindholme. There is no
evidence that Mr McAllister used drugs at Lindholme in the eleven months before
his release. Prison staff noted that Mr McAllister showed a willingness to address
his offending behaviour and comply with future licence conditions.
24. On 9 March 2020, the Parole Board directed Mr McAllister’s release from prison. A
recommendation was made for Mr McAllister to live at an AP so he could receive
closer supervision and community substance misuse support.
25. A nurse at Lindholme saw Mr McAllister before his release. The nurse raised no
concerns about his fitness to be released, noted that he was not taking any
medication, and that he reported no mental health issues and had no thoughts of
self-harm. The nurse also offered Mr McAllister naloxone and explained how the
medication should be used in the event of an opiate overdose. Mr McAllister
declined to take the medication with him because he did not intend to use drugs.
(Naloxone is a medication used as an emergency antidote for overdoses caused by
heroin and other opiates. It is used to counter the life-threatening effects of
depressed breathing in an opioid overdose and is administered to provide a window
of time in which to seek further emergency assistance. It does not need to be
administered by a medical professional.)
26. On 11 May, Mr McAllister was released on licence from Lindholme to live at Burdett
Lodge AP. His licence conditions included requirements to attend appointments
with his community offender manager (COM), to abstain from using drugs and to
comply with drug testing. Mr McAllister was required to attend the Derbyshire
Recovery Programme to address his issues with drugs and to address his violent
offending behaviour problems at the Resolve Programme. He was required to
report to AP staff at 11.00am and 3.00pm and to be at Burdett Lodge AP between
the hours of 7.00pm and 6.00am.
4 Prisons and Probation Ombudsman
Burdett Lodge Approved Premises
27. At 2.30pm on 11 May, Mr McAllister arrived at Burdett Lodge. A residential worker
completed Mr McAllister’s induction. He gave him information about the AP,
including the AP’s rules, and the additional rules during the COVID-19 lockdown
(about social distancing and only leaving the AP for specific reasons, such as
shopping and medical appointments). The induction also included a discussion with
him about a reduced tolerance to drugs and an increased risk of overdose after
release from prison. The residential worker noted that Mr McAllister intended to
register with a GP practice. He also needed to be tested for drugs twice a week and
alcohol three times a week when COVID-19 restrictions were changed.
28. That day, Mr McAllister spoke to his probation practitioner on the telephone. She
noted that as Mr McAllister had not been assessed as being in crisis, he was unable
to attend the drug and alcohol recovery service while COVID-19 restrictions
remained in place. Mr McAllister said that he had been drug and alcohol free for
eleven months. He was assessed as a low risk of suicide and self-harm and he was
not prescribed any medication. She spoke to Mr McAllister once a week. She noted
that he was feeling stronger, intended to engage with the drug and alcohol recovery
service and was not using illicit substances.
29. Probation records show that a residential worker was allocated as Mr McAllister’s
AP keyworker. A keyworker works with the resident and their probation offender
manager to address any issues that the resident might have. The key worker spoke
to Mr McAllister regularly on the telephone and did not have any concerns.
30. During the seven weeks that Mr McAllister was at Burdett Lodge until his death, AP
staff did not note any concerns about Mr McAllister’s behaviour and he was fully
compliant with his licence conditions. As drug testing at all APs had been
suspended at the time due to COVID-19 restrictions, and AP staff only completed
visual observations of residents. there was no evidence to suggest that Mr
McAllister was under the influence of illicit substances.
Events of 5 and 6 July
31. Probation records show that on 5 July, Mr McAllister left Burdett Lodge at 11.00am
and returned at 3.00pm. He left again shortly after and returned at 7.00pm in
accordance with his licence conditions. AP staff completed welfare checks at
11.00pm. Mr McAllister was in his room and did not express any concerns.
32. At 6.00am on 6 July, a night resident support worker completed a welfare check. He
noted that Mr McAllister was asleep in his bed. He completed a handover with the
AP manager and confirmed that the 6.00am welfare checks had been completed
and that no concerns about Mr McAllister were raised.
33. At approximately 9.40am, an AP resident told staff that he was concerned that Mr
McAllister had taken an overdose. Staff immediately responded and went into Mr
McAllister’s room. The AP manager told us that there was no evidence to suggest
that the resident was taking drugs with Mr McAllister.
Prisons and Probation Ombudsman 5
34. Mr McAllister was lying in his bed and was unresponsive. A residential worker used
her mobile phone to call an ambulance and her colleague left the room to get a
defibrillator. A resident helped the AP manager and a residential worker, and moved
Mr McAllister to the floor to enable staff to start CPR and attached a defibrillator in
accordance with ambulance service instructions.
35. At 9.51am, paramedics arrived at Mr McAllister’s room and took over resuscitation
efforts. At 10.41am, a paramedic pronounced that Mr McAllister had died. No
evidence of drug use was found in Mr McAllister’s room.
Contact with Mr McAllister’s family
36. The normal practice when a resident dies in an AP is for the police to inform the
next of kin. The AP manager gave the police Mr McAllister’s mother’s details as he
had named her as his next of kin. The next day, he telephoned Mr McAllister’s
mother to offer his condolences and support.
37. The Probation Service did not contribute towards the cost of Mr McAllister’s funeral,
in line with national policy. During the initial report consultation stage, the Approved
Premises Area Manager asked Mr McAllister’s family to contact him to discuss the
funeral contribution.
Support for residents and staff
38. After Mr McAllister’s death, the AP manager offered immediate support to the staff
on duty. Support was offered to all the staff who worked at the AP the next day.
39. Staff held a meeting and told all the residents that Mr McAllister had died and
offered support. Notices were posted.
Post-mortem report
40. The post-mortem report gave Mr McAllister’s cause of death as combined drug
toxicity. Mr McAllister also had bronchopneumonia which did not cause but
contributed to his death. The post-mortem report found that Mr McAllister had a
level of tramadol, buprenorphine and pregabalin in his blood above the level that is
usually associated with therapeutic use. Mr McAllister also had an underlying chest
infection that compromised the use of his lungs.
6 Prisons and Probation Ombudsman
Findings
Substance misuse
41. Mr McAllister had a history of substance misuse and was referred to the community
drug and alcohol service on his release from prison. There was no evidence or
intelligence to indicate that Mr McAllister had used drugs at Lindholme and he said
he wanted to remain drug-free.
42. AP staff gave Mr McAllister information about the risk of drug overdose and his
lowered drug tolerance. Mr McAllister told his probation practitioner that he had
been drug free for eleven months and he displayed a positive attitude towards
engaging with drug recovery services. Mr McAllister was referred to substance
misuse services to help prevent the possibility of relapse, but he died before he had
contact with them.
43. Once the induction process was completed, Mr McAllister was free to leave the AP.
Staff had no reason to consider that he was leaving the AP to buy drugs and could
not have prevented him from doing so. The AP staff who had contact with Mr
McAllister said he appeared normal and did not present as being under the
influence of drugs. In May 2020, the Probation Service issued standard operating
procedure advice to all APs which said that drug testing would remain suspended
due to the COVID-19 pandemic. We are satisfied that staff had no reason to
suspect Mr McAllister had returned to drug use or take any specific action to
manage this.
44. Prison records show that before his release from Lindholme Mr McAllister had
displayed a positive attitude towards change and there was no evidence of drug
use. Although staff contact with Mr McAllister at Burdett Lodge was more limited
than would normally have been the case due to the COVID19 pandemic, none of
the staff who had contact with him in the hours leading to his death considered that
he was under the influence of any substances and he raised no concerns with staff.
45. The supply of naloxone (used to reverse an opioid overdose) is part of a harm-
reduction approach in reducing drug-related deaths. In November 2021, HMPPS
completed the roll-out of naloxone to all APs. We cannot say whether the outcome
would have been different in Mr McAllister’s death if staff had access to naloxone.
However, we are satisfied that staff at Burdett Lodge are trained to recognise the
signs of an opioid overdose and how to administer naloxone.
Inquest
46. At the inquest, which took place on 23 April 2021, the Coroner concluded that Mr
McAllister’s death was drug 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