Cook, Robert

Independent investigation into
the death of Mr Robert Cook,
on 9 July 2023, following his
release from HMP Bullingdon
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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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 HMPPS in ensuring the standard of care received by
those within service remit is appropriate then our recommendations should be
focused, evidenced and viable. This is especially the case if there is evidence of
systemic process failures.
4. Mr Robert Cook died of opioid (heroin and metonitazene) poisoning and cocaine
toxicity on 9 July 2023, following his release from HMP Bullingdon on 28 June. He
also had hepatitis C infection, which contributed to but did not cause his death. Mr
Cook was 42 years old. We offer our condolences to those who knew him.
5. Eight days before he was sent to prison, Mr Cook was admitted to hospital following
a drugs overdose. Although this information was received at Bullingdon via a
hospital discharge note, no one took any further action and Mr Cook was not
referred to the prison’s substance misuse service.
Prisons and Probation Ombudsman 1
The Investigation Process
6. We were informed of Mr Cook’s death on 19 July 2023.
7. The PPO investigator obtained copies of relevant extracts from Mr Cook’s prison
and probation records.
8. We informed HM Coroner for Birmingham and Solihull 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 Cook’s next of kin to explain
the investigation and to ask if he had any matters he wanted us to consider. He did
not respond.
10. The initial report was shared with HM Prison and Probation Service
(HMPPS). HMPPS found two factual inaccuracies in the report, which have been
amended accordingly.
2 Prisons and Probation Ombudsman
Background Information
HMP Bullingdon
11. HMP Bullingdon is a category B local and resettlement prison, serving the courts of
Oxfordshire, Berkshire, Buckinghamshire and Wiltshire. It holds up to a maximum of
1,100 prisoners. Practice Plus Group provide healthcare and GP services and
Oxford Health NHS Foundation Trust provide mental health services at the prison.
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 Prisons
13. The most recent inspection of HMP Bullingdon was in October to November 2022.
Inspectors reported that prison leaders had focused attention on the main security
risks, including the supply of drugs. They found that, although intelligence indicated
that drugs were still too prevalent, there was evidence in their prisoner survey that
aspects of the prison’s drugs strategy were effective.
Prisons and Probation Ombudsman 3
Key Events
14. On 17 May 2023, prior to being sent to prison, Mr Robert Cook overdosed on heroin
and crack cocaine. He was admitted to hospital accident and emergency where
naloxone (medication to counter the effects of opiate overdose) was administered.
He was discharged on the same day.
15. On 25 May, Mr Cook was convicted of common assault and criminal damage and
was sentenced to 10 weeks in prison. He was transferred to HMP Bullingdon. Mr
Cook brought antidepressant medication into prison with him, which he was
prescribed in the community. Healthcare staff continued the prescription. They
referred Mr Cook to the mental health team who continued to support him
throughout his time in Bullingdon.
16. Mr Cook stated on arrival that drugs and alcohol had never been a problem and he
had never had any contact with a drug or alcohol agency. Prison staff recorded that
there were no previous probation reports to confirm this. However, Mr Cook later
said in a self-assessment form that he needed support with drugs and alcohol. He
also said he was prescribed “loads of medication”. Staff recorded that no further
action was required at this stage and that a new referral would be made if a
substance misuse issue was identified in custody.
17. The Head of Healthcare told us that no substance misuse issue was identified when
Mr Cook arrived in custody as he did not disclose a substance misuse history.
When a discharge summary was received for the hospital admission on 17 May,
this was uploaded to his medical record by the healthcare team, who sent a task to
the GP at Bullingdon to action. The Head of Healthcare said that it was uploaded
alongside a second discharge summary that related to an injury Mr Cook sustained
prior to custody. The Head of Healthcare said that the GP only reviewed the
discharge summary for the injury sustained, not the overdose documentation, and
did not therefore complete a referral to the substance misuse service.
18. On 31 May, Mr Cook saw the patient liaison team for a wellbeing appointment and
raised no concerns in relation to substance misuse.
19. On 2 June, Mr Cook spoke with a prison key worker, who said Mr Cook told him
about his mental health and that he took medication that helped with his condition.
Mr Cook told the officer that he was worried about what was going to happen to him
after release because he did not have a place to stay. The officer told Mr Cook he
would speak with the resettlement team to see what could be done, or where Mr
Cook could be referred to for help with his housing issue.
20. The Community Offender Manager (COM) produced an action plan for Mr Cook in
preparation for his release from prison. The resettlement team liaised with her and
made a community resettlement scheme referral for Mr Cook.
21. Mr Cook told prison staff he did not receive a regular income prior to custody and
was claiming benefits. He had a bank account and did not have any debts but
needed support with benefits. On 12 June, an email was sent to Job Centre Plus
who booked an appointment for Mr Cook.
4 Prisons and Probation Ombudsman
22. On 13 June, the prison employment lead saw Mr Cook, where he declined a referral
to Reconnect (supporting vulnerable people leaving prison to access or transition
health or care needs to community-based services).
23. The COM told us that prior to Mr Cook’s release she had spoken to him after a call
from the prison offender manager (POM). Mr Cook was concerned about being
recalled if he could not report to the probation office in time on his release. Mr Cook
did not initially want to return to the Birmingham area, where he had previously
lived, but felt it was probably better in the long run as he was away from negative
influences, such as drugs and drink, that he had encountered in the area in which
he had most recently lived.
24. The COM said that there was no indication that Mr Cook was provided with a
community-based appointment with Change Grow Live (CGL) the drug support
provider ahead of his release. She told us that this would usually be initiated by the
drug intervention team in prison.
25. On 28 June, Mr Cook was released from prison. He was not offered naloxone on
release, as no one had identified that he had a relevant substance misuse history.
Release accommodation was arranged for Mr Cook with Nexus Housing, who
provide supported accommodation for homeless and vulnerable adults in
Birmingham.
Post Release
26. The COM told us that she met Mr Cook from the train station on the day of his
release, as he had been anxious about getting lost. She asked Mr Cook what
support he was looking for in relation to his drug use. He said his main aim was to
stay drug free and he felt positive about this. She said that she would follow this up
with Mr Cook at their next meeting.
27. Mr Cook then went to his release accommodation by taxi, which probation paid for.
Following his arrival, a support worker contacted the COM and said that Mr Cook
was fine.
28. On the same day, the COM made a referral for future accommodation, and
identified staff to help Mr Cook register with a GP and apply for benefits.
29. Mr Cook’s next appointment with probation was arranged for 5 July. The COM said
that she was ill and did not attend but Mr Cook was told he should still attend and
would be seen by the duty officer. Mr Cook did not attend having said that he was
concerned he did not have the means to get to the office. She said she had advised
Mr Cook to attend the office and that he would be reimbursed until his benefits were
established. She said this was the last communication she had with Mr Cook.
Circumstances of Mr Cook’s death
30. On 9 July, Mr Cook’s friends found him deceased in a room at a residential home. It
was not the accommodation that probation had secured for him on release. Police
attended and found drug paraphernalia in the surrounding area.
Prisons and Probation Ombudsman 5
Post-mortem report
31. The post-mortem examination concluded that Mr Cook died of opioid (heroin &
metonitazene – a synthetic opioid) poisoning and cocaine toxicity, with hepatitis
C infection a secondary contributory factor.
6 Prisons and Probation Ombudsman
Findings
Head of Healthcare To Note
32. Just over a week before he was sent to prison, Mr Cook was admitted to hospital in
an emergency following an overdose of heroin and crack cocaine. When he arrived
at Bullingdon, Mr Cook said that he had no drug or alcohol issues, and staff did not
therefore refer him to the prison’s substance misuse service.
33. While a hospital discharge summary detailing his overdose was subsequently
received at Bullingdon, this was mistakenly overlooked. As a result, no one referred
Mr Cook to the substance misuse service as should have happened. This also
meant that no one referred Mr Cook to community drugs services ahead of his
release and he was not offered naloxone on release.
Inquest
34. The inquest into Mr Cook’s death concluded on the 13 May 2024. The coroner
confirmed that Mr Cook’s death was drug related.
Adrian Usher
Prisons and Probation Ombudsman May 2024
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