Jones, Craig

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Craig Jones
on 1 June 2022, following his
release from HMP Cardiff
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
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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 Craig Jones died of aspiration pneumonia caused by the consumption of alcohol
and drugs, including heroin, on 1 June 2022 following his release from HMP Cardiff
on 26 May. He was 44 years old. We offer our condolences to those who knew him.
5. Mr Jones had a history of substance misuse. He received appropriate support in
prison but then refused to engage with the community substance misuse team after
his release.
6. We did not find any issues of concern. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Jones’s death on 23 June 2022.
8. The PPO investigator obtained copies of relevant extracts from Mr Jones’s prison
and probation records.
9. We informed HM Coroner for Cardiff of the investigation. He gave us the results of
the post-mortem examination. We have sent the Coroner a copy of this report.
10. The Ombudsman’s family liaison officer contacted Mr Jones’s mother, to explain the
investigation and to ask if she had any matters she wanted us to consider. She
raised no issues but asked for a copy of our report.
11. 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 Cardiff
12. HMP Cardiff is a category B local prison which holds up to 779 male prisoners who
have either been convicted or are on remand. It is managed by HMPPS. The health
provider is Cardiff and Vale University Health Board, who operate 24 hours a day,
with a nurse on site at all times. The substance misuse service provider is G4S and
Cardiff University Health Board.
Probation Service
13. 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
14. On 25 June 2021, Mr Craig Jones was convicted of grievous bodily harm and was
sentenced to 30 months in prison. He was sent to HMP Parc.
15. On 10 January 2022, Mr Jones was released on Home Detention Curfew (HDC,
allows certain prisoners the opportunity to serve the last part of their sentence at
home or another suitable address for a maximum of six months).
16. On 19 February, Mr Jones’s HDC licence was revoked because he had
accumulated 13 hours of unauthorised absences from his approved address.
17. On 21 February, Mr Jones was recalled to prison and sent to HMP Cardiff.
18. When he arrived, his urine sample tested positive for opiates, benzodiazepine (a
sedative) and cannabinoids. Mr Jones said he had previously used drugs but did
not currently do so regularly. He declined a referral to the substance misuse
service.
19. During his secondary health screening the next day, Mr Jones admitted to using
Subutex (an opiate) while in the community. Mr Jones said he occasionally used
cannabis and admitted to buying illicit drugs, most recently on 20 February, the day
before he was recalled. The nurse spoke to Mr Jones about harm reduction and
reminded him of the risks of illicit drug use. She said he would be supported by the
Dyfodol team (a local drug and alcohol service that work in the prison and Cardiff
community). However, Mr Jones declined to engage with the Dyfodol team.
20. During the secondary health screening, a mental health nurse saw Mr Jones. He
told her he was prescribed diazepam for his anxiety, but he had no mental health
concerns and did not require any support from the mental health team. The nurse
made a note to review Mr Jones the following day if he had not received his
diazepam prescription.
21. That day, a GP in the prison reconciled Mr Jones’s medication and noted that he
had not been prescribed his regular medications (sertraline and mirtazapine) in the
community since May 2021. The GP noted that Mr Jones would not be prescribed
any medication due to the significant break in treatment.
22. However, later that day, the GP received confirmation that Mr Jones was on a
diazepam prescription, so the GP started Mr Jones on a benzodiazepine
detoxification. He prescribed 5mg of diazepam twice a day.
23. On 23 February, a nurse reviewed Mr Jones after he reported benzodiazepine
withdrawal symptoms. The nurse observed a light tremor but could not feel it. Mr
Jones said he felt more anxious. Mr Jones said he started using heroin after his
girlfriend died by suicide, but he had not used heroin for years, and said the
diazepam helped him with his anxiety. The nurse discussed diazepam and how it
was not effective over a long period of time. She advised Mr Jones to speak to the
Dyfodol team about a counselling referral to help him with his past trauma. There is
no evidence to suggest Mr Jones spoke to the Dyfodol team about counselling.
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24. On 24 February, a nurse saw Mr Jones on the wing again and she noted he was
very anxious. He said he was worried about the diazepam being reduced and kept
asking for the dosage to be increased. He was advised this would not be the best
option for him as he would still have to reduce at some point, and he was not
withdrawing so they would not increase his dose. Mr Jones said he had taken illicit
Subutex the previous night, and the nurse advised him of the risks and that he
could be putting his other medication at risk. After this discussion, the nurse asked
for Mr Jones’s dose to not be increased but to extend his benzodiazepine
detoxification for a little longer.
25. Later that day, a GP agreed to extend the detoxification for two weeks.
26. On 3 March, Mr Jones’s diazepam prescription was reduced to 5mg once a day,
and this ended on 10 March.
27. On 30 March, a GP saw Mr Jones because he requested a prescription for
diazepam. The GP raised his concerns about long-term benzodiazepine use and
was not willing to restart the prescription. The GP offered Mr Jones fluoxetine (an
antidepressant) as an alternative, but he declined. Mr Jones said he did not know
what to do if he could not get diazepam and he would look for drugs on the wing.
The GP explained again that he would not prescribe unsafe medication to him. Mr
Jones then said he would try fluoxetine.
28. On 1 April, Mr Jones started his fluoxetine medication.
29. On 26 May, Mr Jones was released with a seven-day supply of fluoxetine. Mr Jones
was not seen by healthcare or given any advice on the risks of overdose by the
substance misuse team before he was released and was not released with
naloxone (which can reverse the effects of an opiate overdose) because he was not
engaging with the substance misuse team.
Pre-release planning
30. On 24 April, Mr Jones’s community offender manager (COM) had a meeting with Mr
Jones by video link. She discussed where Mr Jones was going to live on release.
Mr Jones said he wanted to live with his mum and was not willing to go into
temporary accommodation as he had a bad experience in the past. Mr Jones also
said he had not used any drugs while in prison and he refused to work with Dyfodol
in the community, but he would consider self-referring if he needed to.
31. On 26 April, the COM completed an application for accommodation assistance to
Rhondda Cynon Taf County Borough Council. As Mr Jones wanted to live with his
mother on release, and because he refused to live in temporary accommodation,
the council considered his mother’s address suitable and did not complete a
housing assessment.
32. On 23 May, the COM completed a housing risk assessment form, which was sent to
a housing officer in Rhondda Cynon Taf County Borough Council. Although Mr
Jones wanted to live with his mother on release, the COM was not able to confirm
this with his mother prior to release, and therefore tried to put other measures in
place so that Mr Jones was not released homeless. These other measures included
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completing an application for accommodation assistance and completing the risk
assessment form to the local council.
33. On 23 May, the COM sent reporting instructions and licence conditions for Mr Jones
to the prison. Mr Jones was subject to two additional licence conditions, one of
which was to comply with any requirements specified by the COM for the purpose
of ensuring he addressed his alcohol and drug abuse, and offending behaviour
problems at Dyfodol. However, Mr Jones declined support from Dyfodol, and the
community Dyfodol team told the COM she could refer Mr Jones into their service if
he started using class A drugs again, but at the time he was abstinent.
Post-release planning
34. On 26 May, Mr Jones was released from prison and attended his initial appointment
at Pontypridd Probation. Mr Jones provided his COM with his mother’s address
(where his mother and the COM had agreed he could stay) and a mobile number.
Mr Jones signed his licence to say he understood his licence conditions.
35. On 1 June, Mr Jones was due to attend an appointment with his COM, but he did
not attend the appointment and he was not answering the phone. His COM decided
to wait until the end of the day to see if he would make contact. However, Mr Jones
did not make contact, so the COM sent him a compliance letter with another
appointment for 7 June.
Circumstances of death
36. Mr Jones visited his friend’s house on 28 May. They both drank a lot of alcohol and
smoked cannabis, and then Mr Jones fell asleep in a chair. Mr Jones’s friend said
that over the next couple of days, he consumed a large amount of alcohol, and it
was not until the morning of 1 June when he tried to wake Mr Jones, that he
realised he was unresponsive. He called the emergency services who confirmed
that Mr Jones was dead.
37. The police were satisfied that there were no suspicious circumstances.
Post-mortem report
38. The post-mortem report concluded that Mr Jones died of aspiration pneumonia
(inhalation of stomach contents into the lungs) in the setting of alcohol, diazepam,
and heroin use. Alcoholic fatty liver disease was listed as a contributing factor.
39. At the inquest held on 7 December 2023, the coroner concluded that Mr Jones’
death was drug related.
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Findings
Substance misuse
40. The substance misuse team and healthcare staff at Cardiff supported Mr Jones with
his illicit drug use. He was referred appropriately, and they addressed his needs
during his time in Cardiff by placing him on a detoxification programme and
extending this when required. However, because Mr Jones declined to work with
the substance misuse team in the community, the continued support available for
Mr Jones after his release to address his illicit drug use was very limited.
41. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman April 2024
Prisons and Probation Ombudsman 7
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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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