Avtar Bhara

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Avtar Bhara,
on 1 August 2022,
following his release from
HMP Exeter
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, 2025
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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 investigated post-release deaths that occur
within 14 days of a prisoner’s release.
3. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
4. Mr Avtar Bhara died from a heart attack on 1 August 2022, following his release
from HMP Exeter on 19 July. Mixed drug toxicity contributed to but did not cause
his death. He was 42 years old. I offer my condolences to his family and friends.
5. Mr Bhara engaged with the integrated substance misuse service at Exeter and was
referred to the Torbay and South Devon drug and alcohol services on release.
6. Mr Bhara declined the option to be released early under the home detention curfew
scheme. Previous issues in temporary accommodation meant that he was released
homeless.
7. After his release from prison, Mr Bhara was seen by ambulance paramedics three
times before his death. He was taken to hospital twice but discharged himself
despite hospital staff informing him that he was at risk of a heart attack.
8. On 1 August, members of the public found Mr Bhara unresponsive in a street in
Torquay. They carried out cardiopulmonary resuscitation (CPR) until ambulance
paramedics arrived. Mr Bhara died later that day in hospital.
9. We did not make any recommendations but are concerned that Mr Bhara’s death
highlights a number of issues about the vulnerability of those being released from
prison, substance misuse and homelessness post-release.
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The Investigation Process
10. The PPO investigator obtained copies of relevant extracts from Mr Bhara’s prison
and probation records.
11. We informed HM Coroner for Plymouth, Torbay and South Devon of the
investigation. He gave us the results of the post-mortem examination. We have
sent the Coroner a copy of this report.
12. The Ombudsman’s family liaison officer wrote to Mr Bhara’s father to explain the
investigation and to ask if he had any matters he wanted us to consider. He did not
respond.
13. We shared the initial report with the Prison Service and the Probation Service.
There were no factual inaccuracies.
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Background Information
HMP Exeter
14. HMP Exeter holds up to 431 adult men and young offenders, and serves the courts
of Devon, Cornwall and Somerset. GP and primary care health services are
delivered by Practice Plus Group. Devon Partnership NHS Trust provide mental
health services and substance misuse services are provided by EDP Drug and
Alcohol Services.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Exeter was in November 2022. Following the
inspection, HM Chief Inspector of Prisons invoked the Urgent Notification protocol
and wrote to the Secretary of State setting out significant concerns. The Chief
Inspector identified that substance misuse services were not well integrated and
patients receiving treatment were not always observed in line with their care plan.
He found that rehabilitation and release planning outcomes were reasonably good,
although too many prisoners were released without an identified address to go to.
Probation Service
16. 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. They
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervises people
throughout their licence period and post-sentence supervision.
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Key Events
17. On 11 May 2022, Mr Avtar Bhara was sentenced to 20 weeks in prison for theft and
sent to HMP Exeter. Before he was sent to prison, Mr Bhara was evicted from his
temporary accommodation by Torbay Borough Council because he had damaged
the property. As a result, the Council said that they would not provide him with
accommodation when he was released.
18. Mr Bhara’s release date was 19 July. He was also eligible to apply for release
under the home detention curfew scheme on 15 June. The scheme enabled
prisoners serving sentences of up to four years to be released early, subject to an
electronically monitored curfew.
19. At his initial health screen, Mr Bhara tested positive for benzodiazepines, opiates,
cannabis and cocaine. He told a prison nurse that he used six to seven bags of
heroin a day and had last used heroin the day before. Mr Bhara also said that he
drank alcohol excessively. A prison GP noted that Mr Bhara had opioid drug
dependence and prescribed him methadone (used to treat symptoms of opiate
withdrawal).
20. Mr Bhara received methadone throughout his time at Exeter. By 9 July, to help
stabilise Mr Bhara in preparation for release, his dose was increased.
21. On 12 May, a substance misuse nurse recorded that Mr Bhara was under the care
of a community drug team. Mr Bhara told the nurse that he spent £70 a day on
heroin, £20 to £50 a day on crack cocaine and £20 a day on psychoactive
substances (PS).
22. In May, Mr Bhara was allocated a prison offender manager (POM).
23. On 16 May, a resettlement officer completed Mr Bhara’s basic custody screen (to
identify the key issues to prioritise in Mr Bhara’s resettlement plan). She recorded
that Mr Bhara said that he was homeless before entering custody. He was also
unemployed. She noted that Mr Bhara would be homeless on release and would
be referred to Interventions Alliance, who coordinate the process to find
accommodation for prisoners being released homeless. Mr Bhara told her that he
had previously worked as a chef and would look for similar work on release.
24. The resettlement officer arranged for Mr Bhara to attend an induction programme to
identify suitable courses for prisoners seeking work. She asked a pre-release
practitioner to arrange a benefits appointment for Mr Bhara on release. Mr Bhara
said that on release, he would see a doctor at the Leonard Stocks Centre (a
homeless hostel owned by the Langley House Trust, a charity which provides
specialist housing and support for people with a history of offending).
25. On 16 May, a substance misuse service administrator referred Mr Bhara to
Shrublands (Torquay and South Devon drug and alcohol service), in line with local
pre-release standards for all prisoners who are prescribed methadone.
26. On 7 June, Mr Bhara chose not to apply for release under home detention curfew,
as he opted not to work with his community offender manager (COM), to secure
release accommodation. The COM told us that he thought that this was because
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Mr Bhara’s proposed release address at a Bail Accommodation and Support
Service (BASS) hostel was not in Torbay.
27. On 4 July, the resettlement officer emailed a referral to Torbay Borough Council as
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.) She explained that Mr Bhara
would be released homeless. She also emailed an Interventions Alliance worker to
ask if there was an update on Mr Bhara’s accommodation. (The worker no longer
works for Interventions Alliance, and his colleague told us that they could not locate
Mr Bhara’s file.)
28. On 12 July, a nurse (an integrated substance misuse service worker) spoke to Mr
Bhara, who told her that he would be released with no fixed abode. Mr Bhara
asked her to contact the Leonard Stocks Hostel on his behalf. She emailed them,
asking if Mr Bhara would be able to have an appointment on release. She told Mr
Bhara that she would update him when they got back to her.
29. On 14 July, the resettlement officer sent Mr Bhara’s patient summary (a record of
medication and medical needs) to the COM and the Interventions Alliance worker,
to support his homelessness application with Torbay Borough Council.
30. On 18 July, a joint team leader at the Leonard Stocks Centre responded to the
nurse. She told her that a referral form would need to be completed and sent to
Torbay Borough Council before an offer of accommodation could be made. She
attached a referral form for completion, but it was not completed. She said that she
did not think that it was completed as Mr Bhara was due to be released the
following day. She gave the nurse the Torbay Borough Council emergency housing
number to give to Mr Bhara to contact them on his release.
31. The joint team leader told the investigator that she was not able to offer Mr Bhara
accommodation because he was in a volatile and abusive relationship with his
girlfriend who already lived in the hostel. She said that she also suspected that Mr
Bhara was supplying drugs to residents at the Leonard Stocks Centre and
supplying drugs in the community.
32. On 19 July, a prison nurse gave Mr Bhara a prescription of naloxone (used to
counter the effects of opioid misuse) and a training leaflet. The nurse also gave Mr
Bhara his discharge medication, including prescribed antidepressants.
33. That day, Mr Bhara was released on licence from HMP Exeter. His licence
conditions required him to report at 11.30am to Mr Gray at the Torquay Probation
Office.
Post-release
34. On 19 July, Mr Bhara reported to the Torquay Probation Office. The COM
explained the terms of his licence, which included that he addressed his drug and
alcohol offending behaviour problems with the Shrublands Substance Misuse
Service. He made an appointment to see Mr Bhara on 26 July.
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35. The joint team leader told the investigator that Mr Bhara stayed at a hotel in
Torquay for the first two nights after his release. She said that she received a
telephone call from hotel staff, stating that the hotel room had been left in a “terrible
state” with drug paraphernalia strewn around.
36. On 20 July, Mr Bhara did not attend an appointment at Shrublands (which had been
made before his release from Exeter). A social worker and senior mental health
practitioner at Shrublands said that his methadone prescription was stopped as a
result.
37. On 22 July, Mr Bhara went to Shrublands and saw the social worker. Mr Bhara told
her that on the day of his release, he intentionally took an overdose of illicit drugs
and prescribed medication. Mr Bhara tested positive for opiates, methadone and
cocaine and provided a negative breathalyser test for alcohol. She said that during
the appointment, Mr Bhara appeared to be sedated, and that he was nodding off
but rousable. Because of his recent intentional overdose and concerns about his
safety and risk of another overdose, she discussed providing a methadone
prescription to him. A non-medical prescriber at Shrublands assessed Mr Bhara
and agreed to prescribe him methadone for supervised consumption. The social
worker referred Mr Bhara to the Rough Sleepers’ Initiative (RSI, Government
funding allocated to local authorities to help prevent and reduce rough sleeping).
She gave Mr Bhara harm reduction advice and details of out-of-hours support for
medical attention and mental health support.
38. At around 4.00am on 23 July, the ambulance service was called to assist Mr Bhara
as had fallen into the sea. Paramedics took him to hospital.
39. A hospital nurse emailed the Torquay Probation Office and said that a discharge
coordinator had spoken to Mr Bhara before his discharge from Torbay Hospital.
The discharge coordinator recorded that Mr Bhara had fallen asleep after taking an
intentional overdose of amitriptyline (a prescribed antidepressant) and fallen into the
harbour. He recorded that Mr Bhara had had an argument with his girlfriend and
was under the influence of heroin, crack cocaine, PS, cannabis, and alcohol when
he fell. The discharge coordinator recorded that he advised Mr Bhara to contact
housing in the hope of securing accommodation, provided clothing for him as his
current clothes were wet and planned to update the drug and alcohol team and the
rough sleepers’ team.
40. On 25 July, the social worker telephoned the pharmacy where Mr Bhara was
receiving his methadone. The pharmacist told her that Mr Bhara had been
attending to receive his methadone. However, following a shoplifting incident on 24
July, Mr Bhara was now banned from the premises.
41. On 26 July, Mr Bhara went to the Torquay Probation Office, where he had an
appointment with the COM. Mr Bhara told him that he had to go to Shrublands to
collect his methadone prescription and left the appointment. The COM made an
appointment to see Mr Bhara at 3.00pm on 1 August. Mr Bhara did not
subsequently attend his appointment at Shrublands.
42. On 28 July, the Ambulance Service was called to see Mr Bhara, who had
abdominal pains. The caller told the operator that Mr Bhara had taken heroin.
Ambulance paramedics found that Mr Bhara’s electrocardiogram (ECG, a test of the
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heart’s rhythm) reading was abnormal, but he refused to go to hospital and signed a
disclaimer to that effect.
43. Later that day, Mr Bhara went to Shrublands, where he saw a recovery coordinator.
Mr Bhara told her that he had used illicit drugs. She told Mr Bhara that because of
the risks and their inability to monitor him, they would be unable to re-prescribe his
methadone over the weekend. She booked a prescribing assessment appointment
for 1 August and discussed overdose risks with Mr Bhara. Mr Bhara told her that he
had naloxone with him.
44. On 30 July, the Ambulance Service was called to see Mr Bhara, who was struggling
to breathe and had chest pains. Mr Bhara went to hospital. Hospital staff carried
out an ECG and told Mr Bhara to stay in hospital because he was at high risk of
having a heart attack. Mr Bhara chose to discharge himself.
Circumstances of Mr Bhara’s death
45. At 11.59am on 1 August, a member of the public telephoned the Ambulance
Service and told them that Mr Bhara was lying on the ground and gasping for air.
Members of the public started cardiopulmonary resuscitation (CPR) before
ambulance paramedics arrived and took over life support. Ambulance paramedics
noted that a man working nearby saw Mr Bhara smoking a pipe 20 minutes earlier.
They took Mr Bhara to hospital where, at 2.40pm, healthcare staff pronounced that
he had died.
46. Mr Bhara’s girlfriend told police that he had used cocaine, heroin, and PS that
morning. She said that Mr Bhara had been sleeping near a car park in Torquay.
Post-mortem report
47. A post-mortem examination established that Mr Bhara died from an acute
myocardial infarction (a heart attack) caused by coronary artery atheroma
(narrowed or blocked blood vessels supplying the heart). Mixed drug toxicity
contributed to but did not cause his death.
48. Toxicology tests detected the following drugs in Mr Bhara’s blood: cocaine, opiates,
PS, cannabis, methadone, amitriptyline, nortriptyline (used to treat nerve pain),
codeine (for pain relief), noscapine (an opium-based cough suppressant),
papaverine (an opium-based drug used for back spasms), paracetamol,
cyclobenzaprine (for muscle spasms), phenylpropanolamine (a decongestant and
appetite suppressant). Naloxone and amiodarone were also detected but these
were given to Mr Bhara by medical professionals during the medical emergency
response.
Support for staff
49. The POM told the investigator that he was not told that Mr Bhara had died. He said
that the first he knew about his death was when he saw the PPO notices informing
prison staff of the investigation. When the COM told his line manager that Mr Bhara
had died, he was offered support services by a senior probation manager.
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Contact with Mr Bhara’s family
50. Police officers informed Mr Bhara’s father that he had died.
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Findings
Substance misuse services
51. Healthcare staff at Exeter referred Mr Bhara to the integrated substance misuse
service and a prison GP prescribed him methadone. He was appropriately referred
to Torbay and South Devon drug and alcohol services. Healthcare staff gave Mr
Bhara his prescribed medication on release. They also gave him naloxone and
explained how to use it.
52. The toxicology report found that Mr Bhara had used several illicit substances in the
time before his death. The post-mortem report found that this contributed to but did
not cause his death. We are satisfied that he received appropriate support in prison
and was referred to appropriate support agencies on release.
Issues to highlight outside of our remit
53. Homelessness on release from prison is a significant and complex challenge. This
was particularly the case for Mr Bhara. He had been evicted from his temporary
accommodation before being sent to prison, and the local council had chosen not to
provide release accommodation as a result of his previous behaviour. He also
refused to apply for release under the HDC scheme, seemingly because he was not
satisfied with the location of the accommodatiovn offered to him.
54. Mr Bhara was appropriately referred to a local hostel for the homeless, but they
could not provide a room for him for reasons including the potential risk to his
partner. He was appropriately referred to Torbay Borough Council under the
conditions of the Homelessness Reduction Act.
55. While we are satisfied that prison and probation staff referred Mr Bhara to
appropriate agencies, Mr Bhara was released homeless. The provision of suitable
accommodation for people leaving prison, particularly for those with complex
vulnerabilities, risks and needs, is an issue that extends beyond the remit of HMP
Exeter or local probation services, and the Department for Levelling Up, Housing
and Communities and local authority may want to be aware of the significant issues
raised in this case.
Inquest
56. The inquest into Mr Bhara’s death concluded on 21 January 2025. The inquest
concluded that Mr Bhara died of natural causes, contributed to by drug misuse.
Kimberley Bingham
Acting Prisons and Probation Ombudsman February 2023.
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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