Harmon, Liam

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Liam Harmon on
3 November 2022, following his
release from HMP Forest Bank
A report by the Prisons and Probation Ombudsman
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© 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 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 Liam Harmon died of multi-drug toxicity on 3 November 2022, eight days after
his release from HMP Forest Bank. He was 39 years old. We offer our condolences
to those who knew him.
5. We found no issues of concern. We make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Harmon’s death on 8 December 2022.
7. The PPO investigator obtained copies of relevant extracts from Mr Harmon’s prison
and probation records.
8. We informed HM Coroner for Manchester of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
9. We requested details of Mr Harmon’s next of kin from HMP Forest Bank, but they
said they did not have any. We contacted the Coroner’s office, but they said they
were unable to share the details with us, and they would ask the next of kin to
contact our family liaison officer if they had any questions or concerns. They did not
contact us.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Forest Bank
11. HMP Forest Bank is a Category B private prison managed by Sodexo. The
substance misuse provider is Sodexo Justice 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.
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Key Events
13. On 11 August 2022, Mr Liam Harmon was charged with burglary and remanded in
custody. He was sent to HMP Forest Bank.
14. Mr Harmon told the reception nurse that he smoked heroin and used seven to eight
bags of crack stones daily. A GP prescribed methadone (medicine used to treat
heroin dependence).
15. On 16 August, a nurse saw Mr Harmon and he told her he was feeling more
agitated, was not sleeping, was aching, and had cramps. He asked if his
methadone dose could be increased. Mr Harmon said he had been using drugs for
years, but it had only become a problem in the last 18 months after his brother died.
Mr Harmon said he wanted to change his life and wanted to work with the recovery
team while in prison. Later that day, a GP increased Mr Harmon’s methadone.
16. On 18 August, a GP changed Mr Harmon’s methadone prescription to
buprenorphine (another medicine used to treat heroin dependency) due to his low
blood platelet levels (an ongoing issue that he had experienced for several years).
17. That day, a nurse noted in Mr Harmon’s medical records that he had been
diagnosed with a psychotic disorder (paranoid schizophrenia) and was previously
prescribed olanzapine (an antipsychotic). However, he was non-complaint with
taking his medication in the community and had not taken his medication for five
months. A previous community mental health referral was rejected because they
considered his needs could be managed by his GP, so he did not meet the criteria
for the prison’s mental health in reach team.
18. On 25 August, a GP increased Mr Harmon’s buprenorphine because Mr Harmon
said his current dose was not sufficient and his cravings were worse in the evening.
19. On 28 August, an officer found Mr Harmon’s buprenorphine concealed in his
pocket.
20. On 31 August, a recovery worker from the substance misuse team spoke to Mr
Harmon about concealing his medication and he said he was being bullied on the
wing for his medication and he did not want to get into a fight because of his low
platelets. Mr Harmon would not tell her who was bullying him on the wing. He was
moved to a different wing.
21. On 1 September, a GP reviewed Mr Harmon. He reduced Mr Harmon’s medication
back to his original dose because he said that Mr Harmon did not need more if he
was concealing it.
22. On 7 September, a GP saw Mr Harmon following a request from him, because he
had found a rash and was worrying about it. The GP assessed that Mr Harmon
would benefit from restarting olanzapine. The GP prescribed olanzapine and noted
that a psychiatric review was planned.
23. On 15 September, Mr Harmon was convicted of burglary and sentenced to 22
weeks in prison. He remained at Forest Bank.
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24. On 3 October, a psychiatrist reviewed Mr Harmon and increased his olanzapine
medication until his release date and requested that he was referred to the
community mental health team (CMHT). There is no evidence on his medical
records that a referral was made to the CMHT. The investigator contacted the
operations manager for the mental health team at Forest Bank, who said this was
an oversight by the nurse who should have completed the referral, and the nurse
took responsibility for it. The operations manager said that this was being
addressed with the nurse and their manager.
25. On 26 October, Mr Harmon was released from Forest Bank.
Pre-release planning
26. On 20 August, a recovery worker from the substance misuse team met with Mr
Harmon to complete his initial assessment. Mr Harmon declined the offer of
naloxone (a medicine that can rapidly reverse the effects of opioid overdose). Mr
Harmon said he used to be able to stop himself from using drugs before it became
an issue, but after his brother died it became a big problem for him. Mr Harmon said
he had not used drugs when he was released previously but he relapsed when he
was homeless and got back into a relationship with his ex-partner.
27. On 20 October, Mr Harmon’s community offender manager (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). There is no evidence
documented that the council received or acknowledged the DTR.
28. On 21 October, a recovery worker from the substance misuse team gave Mr
Harmon his release appointment with Change Grow Live (CGL - community drug
and alcohol recovery service). The appointment was booked for 27 October at
2.00pm. (There is no evidence recorded that Mr Harmon attended this
appointment.)
29. That day, Mr Harmon’s COM completed a CAS3 (a scheme that provides
accommodation support for up to 84 nights after release) referral, and this was
accepted by the On The Out service (OTO - Ministry of Justice funded
accommodation for those who would be homeless on release) on 24 October.
(Although OTO accepted the referral, they were not able to identify where Mr
Harmon would be accommodated until the day of his release.)
Post-release planning
30. On 26 October, Mr Harmon was released from prison and attended his initial
appointment with the duty officer of the day. During this appointment Mr Harmon
said he was told by his COM that accommodation would be available to him, but he
had not yet been given any, so he would go and stay with his friend for now and text
his COM later that day. He also said he would rather go back to prison than be
homeless and start using drugs again. The duty officer told Mr Harmon that she
would contact CAS3 for an update.
31. Later that day, Mr Harmon’s COM called him and asked him to come to the
probation office to meet a housing worker from OTO so that he could move into the
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accommodation sourced for him. He was told on the phone that the housing worker
would only wait until 4.00pm. Mr Harmon did not go back to the probation office that
day.
32. On 27 October, Mr Harmon’s COM called the housing worker from OTO to see if Mr
Harmon had met him the previous evening, but he had not. The housing worker had
tried calling Mr Harmon, but his phone was off. The housing worker told the COM
they could keep his bed available over the weekend until the Monday.
33. The COM tried calling Mr Harmon several times but was unsuccessful, so she had
a discussion with her line manager. They agreed to give him until the following day
to attend the accommodation, and if he did not, recall proceedings would be
actioned.
34. That day, Mr Harmon called his COM and said he had found out some bad
information the night before but did not share what it was. His COM reminded him
that he had to stay at the address provided by OTO (under the terms of a standard
licence, Mr Harmon was expected to live at an address approved by the COM).
35. On 28 October, Mr Harmon called his COM and told her he had met with the
housing worker from OTO and went to the property. He raised concerns about
knowing a lot of the drug dealers in that area and feared repercussions if they knew
his whereabouts. The COM said she would speak to the homeless prevention team
to see if Mr Harmon could be moved to another property.
36. That day, OTO arranged for Mr Harmon to move into another property, but he
declined.
37. Over the next few days, all agencies tried to call Mr Harmon, to support his move
into another property as requested, but he did not answer the phone.
38. On 2 November, Mr Harmon failed to attend his probation appointment at 11.00am
with him COM. She tried to call him several times, but he did not answer. She sent
him his first warning letter.
Circumstances of Mr Harmon’s death
39. On 3 November, Mr Harmon and his friend had been taking various drugs, including
pregabalin and diazepam. Mr Harmon’s friend left him on the sofa while he went to
the shop. When his friend returned from the shop approximately an hour later, Mr
Harmon was unconscious, and his friend called 999.
40. The paramedics gave Mr Harmon adrenaline, glucose, and naloxone, but he failed
to recover and was declared dead.
41. The police informed Mr Harmon’s COM of his death.
Post-mortem report
42. The post-mortem report concluded that Mr Harmon died of toxicity of multiple drugs
together with ketoacidosis secondary to alcohol misuse.
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43. At the inquest held on 10 August 2023, the coroner concluded that Mr Harmon’s
death was alcohol and drug related.
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Findings
Substance misuse
44. Mr Harmon had a history of substance misuse. While he was in prison, he was seen
regularly by the SMS team and warned about the risks and dangers of taking drugs.
He was also offered to be trained in the use of naloxone, but he declined and
therefore he was not released with a supply of this. The SMS team referred Mr
Harmon appropriately to the community SMS team, to ensure he was given
continued support in the community. We are satisfied that both the prison and
probation services did all they could to manage the risks associated with his
substance misuse.
Accommodation
45. We consider that Mr Harmon’s COM appropriately prepared for his release. She
liaised with external support agencies, arranged accommodation through CAS3
accommodation services and advised Mr Harmon of the potential options prior to
his release.
46. Furthermore, his COM continued to support Mr Harmon with finding appropriate
accommodation once Mr Harmon raised his concerns about the suitability of the
initial accommodation found for him. His COM was aware of the risks associated
with this and tried to support Mr Harmon with relocating.
Mental health services
47. Despite a psychiatrist recommending a referral to the community mental health
team, this was not completed by the nurse at Forest Bank. The nurse did not
remember why they did not complete the referral and took full responsibility for the
oversight. The mental health team operations manager said all the team were
aware that the practice of contacting criminal justice liaison teams in the community
as a safeguard should be applied in every case. We are satisfied this is being
addressed and make no recommendation.
Adrian Usher
Prisons and Probation Ombudsman May 2024
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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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