Individual at Ranby

Investigation into the circumstances surrounding the
death of a man who died in May 2006 within 24 hours
of being released from HMP Ranby.
Report by the Prisons and Probation Ombudsman for
England and Wales
June 2006
This is the report of the investigation into the death of a man on 31 May 2006.
The man had been released from HMP Ranby on 30 May without licence
having completed his prison sentence.
The man arrived at Ranby from HMP Nottingham on 20 March 2006 to
complete his sentence. The man was seen at Ranby by drugs counsellors.
He refused all attempts of intervention.
The man was also seen by the resettlement team prior to his release where a
number of courses were identified for him to enhance his employment
opportunities. The man accessed a number of options at a housing forum,
held at Ranby. Accommodation was arranged for him at Nottingham YMCA.
The man was discharged from Ranby on 30 May 2006. Sadly he was found
within 24 hours of his release in a Nottingham street having died from an
apparent drugs overdose. This was despite the very good work carried out by
staff at Ranby to reintegrate the man into the wider community.
I would like to extend me condolences to the man’s family for their loss. I
would also like to thank, the Governor of Ranby, and her staff for their help
and co-operation during this investigation. I would like to extend my thanks to
Nottingham Police for their assistance in this matter, in particular a Detective
Sergeant.
This report makes no recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman 2008
CONTENTS
Summary
The Investigation Process
HMP Ranby
Events prior to 30 May 2006
Events of 31 May 2006
Post Mortem report
Findings and conclusions
Recommendations
SUMMARY
1. The man was sentenced to a total of eight months imprisonment at
Nottinghamshire Magistrates Court. He was transferred to Ranby from
HMP Nottingham on 20 March 2006. The man was known by drug
counsellors at Ranby and declined any form of help. He was also seen
by members of the resettlement team. The resettlement team help
prisoners to re-establish themselves into the community through
helping them find work and accommodation upon release. The
resettlement team were able to facilitate the finding of accommodation
for the man upon his release at Nottingham YMCA.
2. The man was discharged from HMP Ranby on the morning of 30 May
2006. He had with him a discharge grant of £46 cash. A member of the
YMCA staff was due to collect the man and another prisoner from
Ranby. Unfortunately the vehicle that was collecting the man broke
down, the man was therefore, not collected and he and a fellow
prisoner were issued with travel warrants to travel on their own to
Nottingham. Sadly the man was found within 24 hours of his release in
a Nottingham street having apparently died from a drugs overdose.
THE INVESTIGATION PROCESS
3. The investigation was formally opened at HMP Ranby on 6 June 2006
by my investigator. The Governor and her staff produced the man’s
core record and a number of other documents for examination. Notices
were issued to staff and prisoners telling them of the investigation. My
investigators were given unrestricted access to the prison, staff and
documentation relating to the man. My investigators were also able to
speak with a Detective Sergeant of Nottingham Police in relation to
issues of common interest. The head of the Care Assessment Referral
and Through Care (CARAT) team was formally interviewed. CARAT
workers work with prisoners who want to reduce their drug abuse.
Other staff were spoken to as part of the investigation.
4. A family liaison officer from my office has written to the man’s
stepfather explaining the role of the Ombudsman.
5. My investigators wrote to HM Coroner to inform him of the nature and
scope of my investigation and to request a copy of the Post Mortem
Report. Upon completion, this report will be sent to the coroner to
assist him in his enquires into the man’s death.
HMP Ranby
6. Ranby is a category C male adult training prison. Converted in the
early 1970’s from its original use as an Army camp, some old billets still
remain. Some purpose built accommodation was added in 1980’s. Two
new wings opened in February 1996 and a further two new wings were
opened in summer 1998.
7. The prison was inspected in an unannounced visit by HM Chief
Inspector of Prisons in March 2005 who commented:
‘Resettlement, including drug treatment and follow up, was well managed
and integrated. A number of external agencies were involved, and
prisoner’s need and risks were being identified through assessment
systems.’
Events prior to 30 May 2006
8. The man was remanded in custody pending his court appearance. He
was sentenced to a total of eight months imprisonment at Nottingham
Magistrates Court on 16 February 2006. The man was initially
remanded to Lincoln prison where he was interviewed by a CARAT
worker.
9. The man gave his history of drug use. He admitted to injecting and
smoking both crack cocaine and heroin. He explained that he smoked
cannabis and took ecstasy at weekends and his drug habit cost him in
excess of £500 per week. He commented that he would like to access
treatment on release from prison.
10. He was subsequently transferred to Nottingham prison on 21 February
and then Ranby on 20 March.
11. He was seen by a CARAT worker at Ranby on 21 March to discuss
options for his release. He was again seen on 3 April and told his
CARAT worker that he did not want to cooperate with any drugs
programmes. Although the benefits of the scheme were explained to
him, the man was not willing to engage with the CARAT’s team.
12. He was seen on 10 May, by the head of the CARAT team at Ranby.
The head of CARAT had known the man for three years, from his
previous periods of custody. She described him as a likable individual
with whom she had a good interaction. The purpose of her meeting
was to try and engage the man with the CARAT’s team. He refused
any CARAT intervention.
13. The resettlement team help prisoners who are due to be release find
employment and accommodation where needed. An officer from the
team saw the man, and secured accommodation for him on his release
at the YMCA in Nottingham. An appointment was made for the man by
the resettlement team for him to attend the Nottingham benefits on 31
May.
Events of 30 May 2006
14. The man and a fellow prisoner were both released together with the
intention of being driven to the YMCA, by a member of the YMCA staff.
However, the vehicle that was due to collect them broke down and the
man and the other prisoner were issued with a rail ticket by the prison.
15. Prior to his release the man was offered a ‘tolerance overdose
information pack’. This is a pack supplied by Ranby which explains the
dangers of abusing drugs whilst an individual’s tolerance to such drugs
has been reduced. The man refused to take the pack and signed a
form to say he had been offered it.
16. The man and the other prisoner travelled by train together to
Nottingham. It is known through the police investigation that together
they collected needles and drug taking paraphernalia prior to buying
together three crack cocaine and three heroin deals for fifty pounds.
The man brought a further two deals of crack cocaine.
17. The drugs purchased were injected by both men over the following
hours. They last injected themselves at 11:30pm whilst in an alley in
Nottingham. They both fell asleep.
Events of 31 may 2006
18. The other prisoner woke at 7:30am and realised the man was dead. He
placed him into the recovery position, asked a passer by to call an
ambulance and waited with the man until the ambulance and police
arrived.
19. It was confirmed by paramedics that the man had died. The man was
formally identified by his step father later that day.
20. The other prisoner was arrested and interviewed by the police and the
case referred to the Crown Prosecution Service.
Post Mortem
21. The post mortem of the man was carried out on 1 June. The doctor
commented:
22. ‘This man died in circumstances suggestive of an overdose. He had a
large amount of blood in his stomach and this may have contributed to
the cause of death. However, toxicology results are consistent with a
recent potentially fatal intake of heroin.’
Findings and Conclusions
23. The man was no stranger to prison. The CARAT team at Ranby
worked hard to engage with him. Despite their best efforts the man
chose not to voluntarily engage with them. In doing so the man
effectively closed the door on the opportunity of being supported within
a multi agency arena. The resettlement team worked with the man to
find him accommodation, and arranged his first meeting at the
Nottingham benefits office on the day after his release.
24. Sadly the man took the first opportunity on leaving prison to abuse
heroin and crack cocaine at a time when his tolerance to those drugs
would have been low. Tragically the consequences proved fatal.
Recommendations
25. I make no formal recommendations
Good practice
26. I commend the CARAT team and resettlement teams at Ranby in
working hard to re-establish the man back into the community.