Barry Lightbown

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,
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Barry
Lightbown, a resident at
Bowling Green Approved
Premises, on 11 May 2021
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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
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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.
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.
Mr Barry Lightbown was found hanged in the community while a resident at Bowling Green
Approved Premises. He was 45 years old. I offer my condolences to Mr Lightbown’s family
and friends.
There have been no self-inflicted deaths at Bowling Green in the previous three years.
Although he had some risk factors for suicide and self-harm, my investigation found that
there was nothing in Mr Lightbown’s behaviour while he was at the approved premises to
indicate that he would take his life.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman May 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 8
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Summary
Events
1. Mr Barry Lightbown had a history of domestic violence and harassment towards his
ex-partners. He was subject to restraining orders and was not allowed contact with
his children.
2. In January 2021, Mr Lightbown was convicted of breach of a restraining order
preventing him from contact with his ex-partner. He was sentenced to 26 weeks in
prison and sent to HMP Preston. Mr Lightbown transferred to HMP Lancaster
Farms on 23 February.
3. On 27 April, Mr Lightbown was released on licence to Bowling Green Approved
Premises (AP).
4. Mr Lightbown was pleasant to staff and residents and said he was looking forward
to a fresh start. He initially complied with all the rules at Bowling Green, signing in
when required, completing his induction and obeying the curfew. Staff assessed Mr
Lightbown’s risk of suicide and self-harm as low during his induction at the AP. He
received a warning on 29 April after he contacted his ex-partner.
5. On 10 May, Mr Lightbown did not return to the AP for the midday sign in. Staff
reported him to his community offender manager who decided that he had
breached his licence conditions and should be recalled to prison. Staff reported Mr
Lightbown to the police as unlawfully at large.
6. That day, Mr Lightbown contacted his son and ex-partner, apologising for his
behaviour and indicating that he planned to kill himself. The police found Mr
Lightbown hanged in a wooded area on 11 May.
Findings
7. Mr Lightbown had some risk factors that indicated he might be at risk of suicide and
self-harm, but we found no evidence that staff should have considered his risk to be
raised during his period at period at Bowling Green AP.
8. We are satisfied that AP staff appropriately assessed Mr Lightbown’s risk of suicide
and self-harm.
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The Investigation Process
9. HMPPS notified us of Mr Lightbown’s death on 12 May 2021.
10. The investigator issued notices to staff and residents at Bowling Green Approved
Premises, informing them of the investigation and asking anyone with relevant
information to contact her. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Lightbown’s prison
and probation records. She interviewed one member of staff on 9 November 2023.
12. The investigation was delayed awaiting the outcome of the Independent Office for
Police Complaints (IOPC) investigation.
13. We informed HM Coroner for Cumbria of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
14. We wrote to Mr Lightbown’s son to explain the investigation and to ask if he had
any matters he wanted us to consider. He did not respond to our letter.
15. 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
Bowling Green Approved Premises (AP)
16. Approved Premises (formerly known as probation and bail hostels) provide an
enhanced level of residential supervision in the community. The National Probation
Service, Northwest Area, manages Bowling Green Approved Premises in Carlisle.
Residents must be aged over 18. Most residents are required to stay as a condition
of a court order or release licence.
17. Bowling Green AP accommodates up to 24 men. Residents are required to sign in
and out of the building and follow agreed curfews. During induction, staff tell
residents about the premises’ rules and allocate them a key worker who is their
primary contact and who holds one-to-one sessions about the issues in the
offender’s sentence plan. Residents are responsible for their own health and are
required to register at a local doctors’ surgery. As part of the conditions of
residence, staff hold all prescribed medicines and issue them as prescribed.
Previous deaths at Bowling Green AP
18. In 2015, a resident of Bowling Green died by suicide in the community. We
identified some learning about family liaison.
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Key Events
19. On 26 January 2021, Mr Barry Lightbown was sentenced to 26 weeks in prison for
breach of a restraining order and sent to HMP Preston. Mr Lightbown had a history
of domestic violence and harassment and had been in prison before.
20. Prison staff managed Mr Lightbown under Prison Service suicide and self-harm
monitoring procedures (known as ACCT) between 15 and 19 February after he
threatened to self-harm in a letter to his son.
21. On 23 February, Mr Lightbown was transferred to HMP Lancaster Farms.
22. On 3 March, Mr Lightbown’s offender manager noted that he would be released
under Home Detention Curfew (a scheme which allows some people to be released
early from prison if they have a suitable address to go to) to an Approved Premises
(AP).
23. A nurse at Lancaster Farms saw Mr Lightbown before his release. The nurse raised
no concerns about his fitness to be released. Mr Lightbown reported no mental
health issues and reported no thoughts of suicide and self-harm.
24. On 27 April, Mr Lightbown was released on licence to Bowling Green AP. His
licence conditions included requirements to attend appointments with his
community offender manager (COM), not to delete the usage history on any internet
enabled devices and to notify his COM if he developed any intimate relationships
with women. Mr Lightbown was not allowed to have contact with his children without
the approval of his COM and was not allowed to enter the area of Blackburn. He
was required to report to AP staff and sign in at midday and 4.00pm and to be at
Bowling Green AP between the hours of 8.00pm and 6.00am.
25. Mr Lightbown’s licence expiry date was 27 July 2021.
Bowling Green Approved Premises
26. Mr Lightbown arrived at Bowling Green AP at 11.30am. A residential worker
completed Mr Lightbown’s induction. He gave him information about the AP, had a
discussion with him about a reduced tolerance to drugs and an increased risk of
overdose after release from prison and noted that Mr Lightbown intended to register
with a GP. The residential worker completed a wellbeing assessment and noted
that Mr Lightbown denied any thoughts of suicide and self-harm and said he felt
optimistic for the future. He was assessed as a low risk of suicide and self-harm.
27. That day, Mr Lightbown’s COM created a trigger plan which set out the actions that
staff must take if Mr Lightbown failed to comply with the conditions of his licence.
He assessed Mr Lightbown as a very high risk of causing serious harm to his ex-
partner, the victim of his offence. There was a significant risk that Mr Lightbown
would attempt to contact his ex-partner and that he could travel to her address if he
chose to leave Bowling Green. The COM noted that due to his offending history, the
MOSOVO (management of sexual or violent offenders) unit from Lancashire police
would monitor Mr Lightbown’s telephone and internet activity.
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28. Probation records show that a probation services officer (PSO) was allocated as Mr
Lightbown’s AP keyworker. A keyworker works with the resident and their
community offender manager to address any issues that the resident might have.
The PSO saw Mr Lightbown regularly.
29. On 29 April, Mr Lightbown received a formal warning for breaching the conditions of
his licence by deleting his internet search history and attempting to contact his ex-
partner’s daughter. During a meeting with his keyworker, Mr Lightbown said that he
had made a mistake and did not express any other concerns.
30. On 5 May, the COM amended the conditions of Mr Lightbown’s licence to include
that he must not delete his text messages, telephone history or email history and
messages received or sent on social media. Mr Lightbown was not allowed contact
with his ex-partner’s children.
31. Mr Lightbown complied with his amended licence conditions and did not give staff
any cause for concern.
Events of 10 and 11 May
32. On 10 May, Mr Lightbown left Bowling Green at around 8.37am. Mr Lightbown’s
behaviour was normal and AP staff did not have any concerns.
33. In a statement, the COM said that at 10.00am, an independent domestic violence
advocate (IDVA) for Mr Lightbown’s ex-partner contacted him. This was because Mr
Lightbown had updated his WhatsApp profile picture to state he still loved his ex-
partner. He reported this to the MOSOVO unit, who advised that Mr Lightbown had
not breached the conditions of his licence because he had not made direct contact
with his ex-partner. The COM said that AP staff intended to check Mr Lightbown’s
mobile telephone when he returned to the AP to ensure that he was compliant with
his licence conditions.
34. At midday, Mr Lightbown failed to return to the AP. Mr Lightbown’s trigger plan
stated that if he was 15 minutes late for any signing in time or curfew, AP staff
should attempt to contact him on his mobile telephone. If staff were unable to make
contact, AP staff should contact the COM or the out of hours manager.
35. The AP manager told the investigator that AP staff went to Mr Lightbown’s room
when he failed to return. Mr Lightbown was not in his room and staff found an
empty bottle of vodka on the floor. They called Mr Lightbown on his mobile
telephone, but he did not answer.
36. At around 1.00pm, the AP manager contacted the COM and told him that Mr
Lightbown had not returned to the AP. At 1.15pm, the COM contacted the police to
report Mr Lightbown as unlawfully at large. He gave the police details of Mr
Lightbown’s ex-partner to ensure welfare checks took place. Mr Lightbown’s licence
was revoked, and he was recalled to prison. The recall paperwork stated that Mr
Lightbown would be arrested and returned to prison.
37. At 1.30pm, the COM contacted the MOSOVO unit to discuss his concerns that Mr
Lightbown could go to his ex-partner’s address. At 2.45pm, the MOSOVO unit
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confirmed that the police had completed a welfare check on Mr Lightbown’s partner
and he had not contacted her.
38. Mr Lightbown’s son contacted the COM at 3.00pm and said that Mr Lightbown had
called him. He said that Mr Lightbown sounded drunk but did not make any threats
of suicide or self-harm.
39. The IDVA contacted the COM at 4.45pm and said that Mr Lightbown had sent a
picture of himself holding a rope to his ex-partner with the message, ‘guess what’s
coming’. Mr Lightbown had also left some possessions with his ex-partner’s
neighbour. The COM immediately contacted the MOSOVO unit to ensure that the
police were aware that Mr Lightbown was now a high risk of suicide and self-harm.
He also sent emails to the force intelligence bureau (FIB) at Cumbria Police and
Lancashire Police to express concern for Mr Lightbown’s welfare.
40. At 8.00pm, AP staff went to Mr Lightbown’s room and noted that he appeared to
have taken some belongings and had urinated on the floor.
41. At 8.30am on 11 May, the police spoke to the AP manager who confirmed that Mr
Lightbown had not returned to the AP.
42. At 12.30pm, the MOSOVO unit told the COM that the police had completed a
welfare check on Mr Lightbown’s ex-partner. She told the police that she had not
heard from Mr Lightbown again.
43. Police officers from Cumbria Police attended the AP at 1.00pm, and searched Mr
Lightbown’s room. Officers found a note from Mr Lightbown to his ex-partner, which
said that he was sorry for his behaviour and that he was going to take his own life.
44. At 5.18pm, the police found Mr Lightbown hanged in a wooded area near
Blackburn.
Information received following the IOPC investigation
45. The IOPC investigation found that Mr Lightbown’s ex-partner contacted Lancashire
police at 1.32pm on 10 May to report that he had breached a restraining order. Mr
Lightbown had telephoned his ex-partner to say goodbye.
46. Mr Lightbown’s ex-partner contacted the police again at 3.24pm and said that Mr
Lightbown was sending her text messages which indicated that he was going to
harm himself. The investigation found that the police did not record the call as a
concern for Mr Lightbown’s welfare and the police continued to treat Mr Lightbown
as wanted rather than a vulnerable person. This meant that the police did not
commence a high-risk missing person investigation.
47. The investigation noted that the FIB at Cumbria Police and Lancashire Police did
not read the COM’s emails until 9.00am on 11 May because the inboxes were not
constantly monitored.
48. An analysis of Mr Lightbown’s mobile telephone by Cumbria Police at 1.00pm on 11
May, revealed that he had switched off his mobile telephone and there was no
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record of his location. Financial checks indicated that Mr Lightbown’s last
transactions were made in the Lancashire area on 10 May.
49. The IOPC investigation concluded that there was no evidence to suggest that the
police may have caused Mr Lightbown’s death. The investigation was unable to say
exactly what time Mr Lightbown died and whether the outcome would have been
different had a missing person investigation been commenced when initial concerns
were raised.
Contact with Mr Lightbown’s family
50. Because Mr Lightbown died away from the AP, Lancashire Police initially assumed
responsibility for informing Mr Lightbown’s son of his death. The AP appointed the
AP manager as family liaison officer, and he made several attempts to contact Mr
Lightbown’s son by telephone and letter. He did not receive a response. He wrote to
Mr Lightbown’s son again on 12 May 2022, to offer support on the anniversary of Mr
Lightbown’s death. He did not receive a response.
Support for prisoners and staff
51. After Mr Lightbown’s death, the AP manager offered immediate support to the staff
on duty. Support was offered to all the staff who worked at the AP the next day.
52. Staff held a meeting and told all the residents that Mr Lightbown had died and
offered support. Notices were posted.
Post-mortem report
53. The post-mortem report gave Mr Lightbown’s cause of death as hanging.
Toxicology did not detect any illicit substances in Mr Lightbown’s blood.
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Findings
Assessment of Mr Lightburn’s risk
54. During Mr Lightbown’s induction, staff completed a wellbeing assessment to assess
his risk of suicide and self-harm. Since Mr Lightbown’s death, AP staff are now
required to complete a Support and Safety Plan (SaSP) to assess and manage
residents who might be at risk of suicide and self-harm. The SaSP was introduced
to all Approved Premises as part of the national Collaborative Approach to Risk and
Emotion (CARE) approach. All residents who arrive at an AP receive a welfare
assessment and an individual support plan. This is completed by the residents and
their keyworker within one day of arriving at the AP. The new approach enables AP
staff to fully assess a resident’s risk of suicide and self-harm and to develop an
appropriate care plan.
55. Mr Lightbown had some risk factors that indicated he was at risk of suicide and self-
harm, including a history of violence against his ex-partner, relationship instability
and lack of family support. Two days after his arrival at the AP, Mr Lightbown
received a warning for deleting his internet search history and attempting to contact
his ex-partner’s children. However, we have not seen any evidence that staff should
have considered Mr Lightbown’s risk of suicide and self-harm to be raised during
his time at Bowling Green.
56. We are satisfied that AP staff considered Mr Lightbown’s risk of suicide and self-
harm and there was no reason for them to think that he might harm himself when he
left the AP on 10 May. We are also satisfied that they took appropriate action when
he failed to return to the AP.
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Inquest
57. At the inquest, which took place between 11 November 2024, the Coroner
concluded that Mr Lightbown died from suicide.
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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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