Burnip, John

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr John Burnip on
29 December 2022, following
his release from HMP Durham
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.
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 John Burnip died of acute alcohol intoxication on 29 December 2022, following
his release from HMP Durham earlier that day. He was 38 years old. We offer our
condolences to those who knew him.
5. We did not find any issues of concern. We make no recommendations.
Prisons and Probation Ombudsman 1
The Investigation Process
6. HMPPS notified us of Mr Burnip’s death on 30 December 2022.
7. The PPO investigator obtained copies of relevant extracts from Mr Burnip’s prison
and probation records. The investigation was then transferred to one of his
colleagues.
8. We informed HM Coroner for Durham of the investigation. He gave us the results of
the post-mortem examination. We have sent the Coroner a copy of this report.
9. The Ombudsman’s family liaison officer contacted Mr Burnip’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond.
10. 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
HMP Durham
11. HMP Durham is a category B prison which holds up to 980 male prisoners who
have either been convicted or are on remand. It is managed by HMPPS. The
mental health provider is Tees, Esk and Wear Valleys NHS Foundation Trust, and
the substance misuse treatment provider is Humankind. Spectrum Community
Health CIC deliver physical health services.
Probation Service
12. 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 Probation
13. The most recent inspection of Durham Probation was in August 2016. This
inspection was a Quality and Impact inspection on the effectiveness of probation
work in Durham. The inspectors reported that despite some promising initiatives in
relation to Through the Gate and social action projects, the quality of some core
probation work had deteriorated since their previous inspection in March 2014.
14. They reported assessments and plans were not good enough, and the rehabilitation
work that should have taken place six months into their sentence was often not
being done. As a result of this, reducing reoffending and public protection outcomes
were less likely to be achieved.
Prisons and Probation Ombudsman 3
Key Events
15. On 8 October 2022, Mr John Burnip was remanded in prison, charged with assault,
and was sent to HMP Durham.
16. Mr Burnip had a history of alcohol and substance misuse but during his reception
screening, he told the nurse that he had no problems with alcohol or drugs. He
subsequently declined to engage with the prison’s substance misuse service.
17. On 3 November, a practitioner from the mental health team completed an initial
mental health assessment with Mr Burnip. During the assessment, Mr Burnip said
he had autism and was prescribed medication to help with some of the effects. He
did not disclose any psychotic illnesses, although his medical records confirmed
previous drug induced and paranoid psychosis. Following this assessment, the
practitioner referred Mr Burnip to the planned care pathway (PCP- a team of care
coordinators who make needs assessments and provide relevant interventions and
discharge planning).
18. On 22 November, a practitioner from the PCP team saw Mr Burnip in their clinic.
They discussed Mr Burnip’s current medication and Mr Burnip said he took the
medication to help him manage his autism and that it was working well for him. The
practitioner told Mr Burnip about the available support in prison if he felt in crisis and
he assured the practitioner he would seek help if he needed it. Mr Burnip remained
on their caseload while in prison.
19. On 9 December, Mr Burnip was convicted of assault and was sentenced to five
months in prison. He was released that day due to time served while on remand.
20. On 15 December, Mr Burnip was recalled to prison because his community offender
manager (COM) had concerns about where he was living, and considered his risk
was not manageable in the community. He was returned to Durham.
Pre-release planning
21. On 16 December, Mr Burnip’s COM completed a Duty to Refer (DTR- 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) application to Durham County Council.
22. On 19 December, Mr Burnip’s COM called Housing Solutions (a team within the
council who provide advice and support on housing issues), but they did not
answer. He left a voicemail for a call back.
23. On 20 December, Housing Solutions emailed Mr Burnip’s COM and said that they
had informed Mr Burnip’s mental health social worker that he would need to contact
the council when he was released.
24. On 21 December, the COM’s manager emailed the council’s housing manager to
escalate their concerns, because no one from the housing team had attended the
professionals meeting and they did not provide any update about the support they
would be offering Mr Burnip on release.
4 Prisons and Probation Ombudsman
25. On Friday 23 December, a multidisciplinary meeting was held between probation,
social services, and the housing team. The housing team said they were struggling
to find Mr Burnip accommodation. They told probation they would have to support
Mr Burnip to call the council on the day of his release because there may be
temporary accommodation available at that point. The meeting attendees decided
that Mr Burnip’s COM would complete a referral to an Approved Premises (AP -
accommodation that provides additional supervision to those who pose a high or
very high risk of harm).
26. On 28 December (the first working day after Christmas), Mr Burnip’s COM
completed an emergency AP referral for his release the following day.
27. On the morning of the 29 December, Mr Burnip was accepted for an AP space for
immediate admission.
28. That same day, Mr Burnip’s COM emailed the Offender Management Unit (OMU) at
Durham to include two additional licence conditions, for Mr Burnip to reside at the
AP and to report to AP staff daily. However, it was too late to change the licence at
that point.
29. Later the same day, the COM had to complete a licence variation, to include the two
additional licence conditions. Mr Burnip was not aware of the two additional licence
conditions added.
30. Mr Burnip’s COM said his mental health social worker was involved in the decisions
made around his release and informed part of his release plan. They had plans to
continue supporting Mr Burnip in the community. (The investigator tried to contact
Mr Burnip’s mental health social worker to find out the support put in place, but no
response has been received.)
Post-release planning
31. On 29 December, Mr Burnip was released from Durham. His licence stated he
needed to attend Durham probation office at 12.00pm, but Mr Burnip failed to attend
this appointment. His COM was therefore unable to tell him about the bedspace at
the AP (which he was unaware of when released due to only being accepted that
morning).
Circumstances of Mr Burnip’s death
32. Mr Burnip was released from Durham at around 10.50am on 29 December. That
afternoon, a member of the public found Mr Burnip slumped in a public toilet and
called the ambulance service. They confirmed that Mr Burnip had died. An empty
vodka bottle was found next to him.
33. The police informed probation staff at around 5.00pm.
Post-mortem report
34. The post-mortem report concluded that Mr Burnip died of acute alcohol intoxication.
Prisons and Probation Ombudsman 5
Findings
Accommodation
35. Mr Burnip’s COM made a DTR application to the local council before his release.
However, the housing department told probation that they were struggling to find Mr
Burnip appropriate accommodation, and he would need to call housing on the day
of his release, as there could be temporary accommodation available at that point.
36. Mr Burnip was considered a vulnerable adult, and probation identified
accommodation as a risk factor for him. Therefore, he was referred to an AP and
accepted for a bedspace. However, this only happened the day of Mr Burnip’s
release and there was no time to update his licence. Mr Burnip did not know about
the AP space when he was released, and he then failed to attend his appointment
at the probation office so remained unaware. As far as he was concerned, he was
released homeless.
37. The provision of suitable accommodation for people leaving prison, particularly for
those with complex risks and needs, is an issue that extends beyond the remit of
Durham or the local probation services. Housing, accommodation services and the
local authority may want to be aware of the issues raised in this case.
Adrian Usher
Prisons and Probation Ombudsman October 2023
Inquest
The inquest, held on 18 April 2024, concluded that Mr Burnip’s death was alcohol related.
6 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