Ben Skivington

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Ben Skivington
on 2 October 2022, following his
release from HMP Hull
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 Ben Skivington died of multi-drug toxicity on 2 October 2022, four days after his
release from HMP Hull. He was 26 years old. We offer our condolences to those
who knew him.
5. We did not find any issues of concern in the pre or post-release planning
processes. We make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Skivington’s death on 4 October 2022.
7. The PPO investigator obtained copies of relevant extracts from Mr Skivington’s
prison and probation records.
8. We informed HM Coroner for Northumberland of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
9. The Ombudsman’s office contacted Mr Skivington’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. She had
concerns related to the medial care Mr Skivington received whilst at HMP Hull.
However, these questions were out of our remit and will be addressed in a separate
letter.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Skivington’s family raised a number of issues that do not impact on the factual
accuracy of this report and have been addressed through separate
correspondence.
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Background Information
HMP Hull
12. HMP Hull is a category B local prison for remanded and convicted prisoners over
the age of 18. Spectrum Community Health CIC provides healthcare services at the
prison.
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 18 August 2022, Mr Ben Skivington was convicted of driving while disqualified
and was sentenced to 12 weeks in prison. He was sent to HMP Hull.
15. Mr Skivington told the reception nurse that he smoked heroin and crack cocaine
and occasionally took benzodiazepines. He also drank alcohol. Mr Skivington’s
urine tested positive for opiates, cocaine and benzodiazepines. The nurse noted in
Mr Skivington’s medical record that he needed to engage with the recovery team for
support while in prison and they would monitor his alcohol withdrawal.
16. That day, a GP prescribed 15ml of methadone (a medicine used to treat heroin
dependency) to Mr Skivington. This was increased by 5ml the next day and then
increased by another 10ml the following day.
17. On 19 August, a member of the Drug and Alcohol Recovery Team (DART) saw Mr
Skivington to complete the initial drug and alcohol psychosocial assessment, but Mr
Skivington declined a referral into their service as he said they did not help him last
time. The DART worker advised him that he would not be released with a
methadone prescription without a referral into the service. Mr Skivington said he
needed a few days to think about it. During this assessment Mr Skivington signed a
consent form for take home naloxone (medicine that rapidly reverses the effects of
opioid overdose) and said he was happy to be given a kit on release.
18. On 25 August, a GP saw Mr Skivington who said he wanted to rapidly detox off his
methadone before his release. The GP tried to get Mr Skivington to recognise the
dangers of doing this, and he said he would think about it overnight.
19. On 28 August, Mr Skivington was sent to A&E due to a rash that had appeared all
over his body. He was diagnosed with scabies and released from hospital on 1
September. While Mr Skivington was in hospital, he refused to take his methadone.
20. On 1 September, when Mr Skivington returned from hospital, he was not given his
methadone due to being out of treatment for several days. The nurse spoke to Mr
Skivington about his refusal to take his methadone and he said he felt fine, he had
no withdrawal symptoms and he had previously dropped from 80ml of methadone
to nothing with no difficulties. Mr Skivington also denied using any illicit drugs.
Pre-release planning
21. On 21 August, Mr Skivington was allocated a community offender manager (COM).
She did not meet or speak to Mr Skivington prior to his release. The COM’s line
manager noted on Delius (probation database) that Mr Skivington was assessed as
low risk, but that the COM needed to consider issues with substance misuse.
22. On 23 August, Mr Skivington’s prison offender manager (POM) met with him to
discuss Home Detention Curfew (HDC - a scheme which allows some people to be
released early from custody if they have a suitable address). Mr Skivington said he
wanted to apply and gave his wife’s and his mother’s address to be checked.
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23. On 13 September, a member of the psychosocial team completed Mr Skivington’s
pre-release plan and gave him the details for the community drug and alcohol
service, but he declined a referral being made to the service. He was also offered a
naloxone kit on release, but he also declined this because he said he did not take
drugs in the community and did not associate with other drug users.
24. On 15 September, Mr Skivington’s HDC application was rejected because he had
ongoing matters at court.
25. On 23 September, his COM had a case discussion with her manager, and it was
agreed to add an additional licence condition for Mr Skivington to comply with any
requirements specified by his COM to address his alcohol and drug offending
behaviour. The COM was aware of his history with drug use and knew that he had
become drug free in prison, however the licence condition was added as a
precautionary measure if he were to relapse in the community. It would have been
at that point the COM would have made a referral to the community drug and
alcohol service.
Post-release management
26. On 29 September, Mr Skivington was released from Hull to his wife’s address. He
attended his initial appointment with his COM, who explained his licence to him, and
he signed it. No issues or concerns were reported during this initial appointment.
27. On 30 September, a multi-agency meeting was held between probation and Social
Services, as Mr Skivington’s hair test had come back positive for drugs. (Social
Services had requested the hair sample for testing as Mr Skivington and his wife’s
baby was in foster care and the couple saw the baby during supervised visits.) The
COM was responsible for referring Mr Skivington to community drugs services
following the positive test but had not done so prior to his death.
Circumstances of Mr Skivington’s death
28. On the evening of 1 October, Mr Skivington arrived home with a large quantity of
diazepam and pregabalin (prescription drugs that are widely abused), many of
which he had already taken. He had an argument with his wife about the drugs and
then went up to the bedroom. Mr Skivington called his mum on several occasions
between 7.56pm and 8.01pm and she said he was very emotional on the phone. Mr
Skivington then took the rest of the drugs he had brought home.
29. At approximately 2.30am on 2 October, Mr Skivington’s wife went into the bedroom
and thought he was asleep, but, when she looked closer, she noticed he was not
breathing. She then called for an ambulance and started CPR while waiting for the
paramedics to arrive. The paramedics took Mr Skivington to the hospital where he
was pronounced dead.
Post-mortem report
30. The post-mortem report concluded that Mr Skivington died of multi-drug toxicity.
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Findings
Substance misuse services
31. Mr Skivington had a history of substance misuse. While he was in prison, he was
seen by DART and warned about the risks and dangers of taking drugs. He was
advised against rapidly reducing his methadone dose, but he chose to stop taking
his methadone script without reducing the dose. He was also trained in the use of
naloxone, but he declined to take a naloxone kit with him on release. The prison did
not complete a referral to the community drug and alcohol service because Mr
Skivington declined the support.
32. Mr Skivington’s COM was aware he had become drug free in prison, therefore did
not make a referral to the community drug and alcohol service prior to his release.
She added a licence condition about complying with any requirements to address
his drug and alcohol use in case he relapsed in the community and would have
made a referral at that point. Unfortunately, Mr Skivington died before she was able
to do so. We are satisfied that both the prison and probation services did all they
could to manage the risks associated with Mr Skivington’s substance misuse.
Adrian Usher
Prisons and Probation Ombudsman July 2024
Inquest
The inquest, held on 17 October 2024, concluded that Mr Skivington’s death was drug
related.
6 Prisons and Probation Ombudsman
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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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