Craig Goddard

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Independent investigation into
the death of Mr Craig Goddard,
a resident at Peterborough
Approved Premises, on 8
December 2019
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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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Craig Goddard died in hospital of pseudomembranous colitis (severe inflammation of
the large intestine) on 8 December 2019 while a resident at Peterborough Approved
Premises (AP). This was caused by antibiotic treatment for a presumed infection, which
was in turn caused by a hypoxic brain injury (reduced oxygen supply to the brain) after Mr
Goddard collapsed in his room two weeks before his death. Mr Goddard was 49 years
old. I offer my condolences to those who knew him.
It was not possible to establish for certain whether Mr Goddard had collapsed after taking
drugs but it is likely that this was the case as he had a history of significant drug use and
he was found with a hypodermic needle in his ankle.
Mr Goddard had been released from HMP Peterborough to Peterborough AP 10 weeks
before he collapsed. I am concerned that, although Mr Goddard failed to comply with the
AP rules and his licence conditions on a number of occasions, enforcement action was not
taken to recall him to prison.
I also note that the opioid antidote naloxone was not available to staff at the AP when Mr
Goddard was found unresponsive in his room. Although this did not affect the outcome in
Mr Goddard’s case, the National Probation Service has since reviewed its drug strategy
and naloxone is now available in all APs. I am pleased that staff at Peterborough AP
received training to use naloxone at the end of July 2021.
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 June 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. On 13 September 2019, Mr Craig Goddard was released on licence from HMP
Peterborough to Peterborough Approved Premises (AP). He had a history of
substance misuse, for which he received ongoing support.
2. When he arrived at the AP, a probation service officer completed his induction,
discussed his licence conditions (which included not using illicit drugs) and the AP
rules, and gave him his prescription medication.
3. Over the next 10 weeks, Mr Goddard tested positive for drugs five times and
negative four times. He was open with staff about his substance misuse. Staff
conducted room searches but they found no evidence that he was taking drugs at
the AP.
4. On 25 October, Mr Goddard was given a final warning for smoking cigarettes in his
room and tampering with the smoke alarm.
5. At 4.15pm on 23 November, a resident, who lived in the room next to Mr Goddard’s,
told staff that there were strange noises coming from Mr Goddard’s room. A
residential worker immediately checked on Mr Goddard and found him
unresponsive with a hypodermic needle in his foot. She pressed her panic alarm
and called for an ambulance.
6. At 4.27pm, an ambulance arrived, and paramedics administered naloxone, an
opioid antidote, five times. Mr Goddard was taken to hospital by ambulance. He
had several seizures on the way and when he arrived at hospital. He remained
unconscious in hospital, where he died of pseudomembranous colitis on 8
December 2019.
Findings
7. Mr Goddard breached his licence conditions by testing positive for drugs and
alcohol a significant number of times. He also admitted to taking drugs and
smoking cigarettes in his room. While all these incidents each warranted a formal
warning and possible recall to prison, he only received one formal warning.
Although AP staff knew of his history of substance misuse, that he tested positive
for drugs a number of times and was at increased risk of an overdose, we are
concerned that staff did not consider recalling him to prison until after he had been
taken to hospital.
8. We are also concerned that staff did not warn Mr Goddard during his AP induction
of his increased risk of an overdose due to his reduced drug tolerance.
9. At the time of Mr Goddard’s death, AP staff were not able to administer naloxone. It
is unlikely that this would have changed the outcome for Mr Goddard as
paramedics quickly arrived and administered it repeatedly. In several previous
investigations into drug-related deaths in APs we recommended that the National
Probation Service should review its drug strategy for APs, including making
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naloxone available in APs. The National Approved Premises Team has now
produced a revised strategy. Naloxone has now been introduced across all APs
and staff at Peterborough AP received their training in July 2021.
10. We are satisfied that probation staff acted promptly when they found Mr Goddard
unresponsive. We found that the first staff member to attend to Mr Goddard when
he was found unresponsive, did not administer first aid as she had not been trained
to do so. While first aid would not have prevented Mr Goddard’s death, we are
satisfied that all members of staff at Peterborough AP are now trained in first aid.
Recommendations
• The Manager of Peterborough AP should ensure that AP staff manage
residents’ risks and needs effectively by:
reviewing licence breaches appropriately in line with AP enforcement policies
and local AP rules; and
reporting licence breaches to Probation Practitioners, for them to issue a
warning or take appropriate enforcement action.
• The Manager of Peterborough AP should update the Head of the National
Approved Premises Team on measures taken to ensure that staff discuss
residents’ reduced tolerance to drugs during induction.
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The Investigation Process
11. The investigator issued notices to staff and prisoners at Peterborough AP informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
12. The investigator visited Peterborough AP on 27 December 2019. She obtained
copies of relevant extracts from Mr Goddard’s records.
13. The investigator interviewed two members of staff at Peterborough AP on 8
September 2020. Interviews were conducted remotely by video link because of the
COVID-19 restrictions in place.
14. We informed HM Coroner for Cambridgeshire and Peterborough of the
investigation. The Coroner gave us the results of the post-mortem examination and
we have sent him a copy of this report.
15. Mr Goddard had not identified a next of kin, and our family liaison officer was
therefore unable to contact anyone about our investigation.
16. The initial report was shared with the National Approved Premises Team (NAPT).
NAPT pointed out some factual inaccuracies, and this report has been amended
accordingly.
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Background Information
Peterborough Approved Premises (AP)
17. Approved premises (formerly known as probation or bail hostels) accommodate
those released from prison on licence and those directed to live there by the courts
as a condition of bail. Their purpose is to provide an enhanced level of residential
supervision in the community, as well as a supportive and structured environment.
Residents are responsible for their own healthcare and are expected to register with
a GP.
18. The National Probation Service manages Peterborough AP. It has 27 single rooms
and two double rooms. Breakfast, a main meal and supper are provided and there
is a communal area for eating and socialising. Each resident has a key worker to
oversee their progress and wellbeing and help them adhere to their individual
licence conditions and the premises’ rules. Staff are on duty 24-hours a day.
Previous deaths at Peterborough Approved Premises
19. Mr Goddard was the second resident to die at Peterborough AP since October
2017. Another resident died from mixed drug toxicity at Peterborough AP two
months before Mr Goddard.
20. Our investigation into that death found a number of similarities with our findings in
our investigation of Mr Goddard’s death. We recommended that AP staff should be
aware of their responsibility to discuss with residents during their induction their
reduced tolerance to drugs and increased risk of overdose. The AP agreed to
implement this recommendation in March 2020 (that is, after Mr Goddard’s death).
21. Following the previous investigation, we also recommended that the National
Probation Service should provide the Ombudsman with an assurance that a revised
drug strategy for APs would be implemented by December 2020, including making
naloxone available in all APs. Although this was delayed by the COVID-19
pandemic, we are very pleased that it has now been implemented.
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Key Events
22. On 14 July 2011, Mr Craig Goddard was convicted of malicious wounding,
possession of an offensive weapon and theft. He was sentenced to eight years in
prison and was sent to HMP Peterborough. He had a history of substance misuse,
for which he received ongoing support in prison.
Peterborough Approved Premises
September 2019
23. On 13 September 2019, Mr Goddard was released on licence from Peterborough
and was required to live at Peterborough AP.
24. When he arrived at the AP, staff agreed to let him go to a nearby shop to buy
tobacco. A probation service officer completed his induction, discussed his licence
conditions and gave him his prescription medication: amitriptyline (for depression)
and olanzapine (for psychosis). She recorded that Mr Goddard smelled of alcohol
when he returned from the shop. She asked him about this, and he said that he
had had one drink. She recorded that it smelled stronger than one drink but that
she did not have time to complete an alcohol test because she was busy with room
checks. She noted that Mr Goddard required drug and alcohol testing that evening
and three times weekly. There is no record that she spoke to him about his
reduced tolerance to drugs.
25. Later that afternoon, Mr Goddard handed in his medication to AP staff and attended
Aspire, a community substance misuse service. That evening, he tested positive
for opiates, cocaine and alcohol. He was not referred to his offender manager
(probation officer).
26. On 15 September, Mr Goddard again tested positive for opiates. He was referred
to his offender manager.
27. On 18 September, Mr Goddard met his offender manager at the AP. He agreed to
ask his GP for a repeat methadone prescription (medication for opioid
dependence).
28. At a keyworker meeting on 23 September, Mr Goddard admitted using illicit drugs
(crack cocaine and heroin). He said that methadone did not help, and he wanted
to be prescribed subutex (a different heroin substitute) again. He was due to visit a
GP the next day. There is no evidence to establish whether he was prescribed
subutex.
29. On 25 September, Mr Goddard met a community wellbeing nurse. She noted that
they discussed abstaining from substances and his reduced drug tolerance.
30. On 30 September, a liaison probation service officer reviewed Mr Goddard. She
noted that he was doing well and that, although he had had some positive tests for
opiates and cocaine, he had also had some negative ones. She noted that his
positive tests were when he was initially released from prison and that since then,
his methadone prescription had been increased. She also noted that he was
engaging well with Aspire and meeting with the AP’s wellbeing nurse.
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October 2019
31. On 5 October, staff searched Mr Goddard’s room but found nothing. There is no
record to say whether the search was routine or based on intelligence. He tested
negative for drugs the following day.
32. On 14 October, Mr Goddard again tested negative for illicit drugs and alcohol but
admitted to having used heroin. Staff searched his room but found nothing.
33. On 16 October, Mr Goddard tested negative for alcohol but positive for cocaine and
heroin. AP staff referred him to his offender manager.
34. On 19 October, Mr Goddard again tested negative for alcohol but positive for
cocaine and opiates. Staff searched his room and found no evidence of drug use
but found cigarette butts. Staff referred him to an Approved Premises Residential
Assistant, who encouraged him to seek substance misuse help from Aspire. Mr
Goddard said he was engaging with Aspire and that he would never use drugs at
the AP. He denied smoking cigarettes in his room. The Residential Assistant noted
that he did not give Mr Goddard a warning for smoking in his room because he did
not have evidence. He asked staff to conduct a room check that night.
35. On 22 October, Mr Goddard tested negative for alcohol and positive for cocaine and
opiates. He was referred to his offender manager and admitted using drugs. His
room was searched but nothing was found.
36. On 24 October, the smoke alarm in Mr Goddard’s room sounded. An Approved
Premises Residential Worker went to Mr Goddard’s room and discovered the
smoke alarm in his room was covered and he could also smell smoke. Mr Goddard
admitted to smoking cigarettes in his room. The Residential Worker told Mr
Goddard that he would issue a final warning (which could result in a resident being
recalled to prison), and that tampering with the smoke alarm had put other residents
and staff at risk. The following morning, this was discussed with the acting
Operational Approved Premises Manager at the time, and Mr Goddard was given a
final warning.
37. On 26 and 31 October and 6 and 8 November, Mr Goddard returned negative drug
and alcohol tests.
November
38. On 10 November, he tested positive for opiates and admitted drug use. His room
was searched but nothing was found. He was referred to his offender manager and
no further action was taken.
39. On 13, 15 and 19 November, Mr Goddard was tested under the AP’s newly
introduced drug testing process (where samples are sent away for testing). The
results of these tests were not received before he was taken to hospital.
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23 November
40. At noon on 23 November, Mr Goddard’s room was checked, and he was found
asleep and snoring. At 1.00pm, his room was checked again because he did not
sign in. It was noted that he was still asleep on his bed but this time, breathing
normally.
41. At about 4.15pm, a resident who lived in the room next to Mr Goddard’s, told staff in
the office that he could hear strange noises coming from Mr Goddard’s room. A
residential worker at the AP went immediately to Mr Goddard’s room, knocked on
the door and let herself in. She said, “Mr Goddard was laying [sic] on his bed, very
wheezy and struggling for breath, kind of unconscious, like not with it, but breathing
kind of, and had a needle in his ankle/foot area.”
42. The residential worker said she ran back to the office, pressed her panic alarm to
get her colleague, and used her phone to call an ambulance straightaway. She
said that she did not perform first aid because she was not trained to do so. She
said that an off-duty staff member, who was previously a nurse, went to Mr
Goddard’s room and waited with her until the first responder arrived. The off-duty
staff member did not attempt first aid. The residential worker said the first
responder arrived about five minutes after her call for an ambulance, and
paramedics arrived a couple of minutes after that.
43. Ambulance records show that paramedics arrived at approximately 4.27pm and
administered naloxone five times. Mr Goddard was taken to Peterborough City
Hospital by ambulance.
44. At 7.25pm, AP staff noted in Mr Goddard’s records that he had repeatedly misused
substances at the premises, and that staff had previously raised concerns that the
AP was offering him a safe space to misuse drugs and that there was a need to
address this. Staff also noted that the previous day, Mr Goddard had asked how
long it took for the results of the new drug tests to come back. Results were not
immediate with the new tests, and so room searches were not conducted, and staff
said they wondered if residents were taking advantage of the new system.
45. At 11.25pm, the duty senior manager consulted the area manager, who decided to
withdraw Mr Goddard’s AP place. He was subsequently recalled to prison.
46. There was regular contact between the hospital and the AP. Mr Goddard remained
in an induced coma on a ventilator and received treatment for kidney failure. He
died in hospital on 8 December. His recall to prison was withdrawn on 13
December.
Contact with Mr Goddard’s family
47. Mr Goddard had no recorded next of kin. Records from a previous stay at
Peterborough AP listed Mr Goddard’s father as a contact to collect his belongings if
he died, but no address was given. The Coroner tried to find an address for Mr
Goddard’s father but was unsuccessful.
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Support for prisoners and staff
48. After Mr Goddard was taken to hospital, the residential worker offered immediate
support to Mr Goddard’s neighbour at the AP. The duty senior manager offered
support to all the AP staff when he became aware that Mr Goddard was in hospital.
Staff were given information about how to access a free, confidential support
service. Staff held a meeting and told all the residents that Mr Goddard had died
and offered support.
Post-mortem report
49. The post-mortem report concluded that Mr Goddard died of pseudomembranous
colitis (severe swelling/inflammation of the large intestine resulting from antibiotic
use). This was caused by antibiotic treatment for a presumed chest infection or
central nervous system sepsis, which in turn was caused by a hypoxic brain injury
(a reduced oxygen supply to the brain), following a collapse of unknown cause. He
also had acute kidney injury (kidney failure) which did not cause but contributed to
his death.
50. No post-mortem toxicology tests were conducted because Mr Goddard had been in
hospital for two weeks before he died (by which time any drugs would have passed
through his system). Although blood samples had been taken when he first arrived
at the hospital, they were no longer available for testing at the time of the post-
mortem.
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Findings
Enforcements of licence conditions
51. Probation national standards say that when an AP resident fails to comply with a
post-sentence supervision period and has not given an acceptable explanation, an
offender manager should issue a warning or take appropriate enforcement action
within six working days of the last failure to comply. When residents do not comply,
AP staff should respond in a way that is proportionate to the level of risk presented,
and should investigate the issue, focusing on indicators of increased risk of re-
offending likely to cause serious harm. Staff should exercise professional
judgement to determine whether a reason provided for non-compliance is
reasonable, taking into account factors such as a resident’s pattern of compliance
and their overall response to their sentence.
52. AP instructions, set out at Section 83 of Probation Instruction (PI) 32/14, say that
even relatively minor repeated breaches might indicate “underlying attitudes that
could give concern over risk” and that offender managers should react quickly,
appropriately and consistently when residents breach rules.
53. When Mr Goddard was released from prison, the Probation Service assessed him
as at high risk of harm. They noted that his risk to himself and others would
increase if he relapsed into substance misuse. During his 10 weeks at the AP, he
had a mix of positive and negative drug and alcohol tests, and he admitted drug
use. He also admitted that he smoked cigarettes in his room, breaching the AP’s
rules. He also admitted drug use. It seems clear that he had relapsed into drug
use and, given his risk of reoffending in these circumstances, we are surprised that
he was given only one formal warning (in connection with tampering with the smoke
alarm in his room).
54. It is clear that most staff knew Mr Goddard well and made decisions with the
positive intention of supporting him and giving him every chance of succeeding in
the community. However, we are concerned that the decisions made did not
support Mr Goddard or manage his risk to himself and others adequately. We
consider that he should have been given more warnings and that a recall to custody
should have been given more serious consideration. We make the following
recommendation:
The Manager of Peterborough AP should ensure that AP staff manage
residents’ risks and needs effectively by:
reviewing licence breaches appropriately in line with AP enforcement
policies and local AP rules; and
reporting licence breaches to Probation Practitioners, for them to issue a
warning or take appropriate enforcement action.
Substance misuse
55. The post-mortem examination was unable to determine whether Mr Goddard’s
collapse on 23 November was due to drug toxicity. However, it appears highly
likely that his collapse was caused by drug use because he was known to be using
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heroin and cocaine and there was a hypodermic needle in his ankle at the time he
was found.
56. We are satisfied that AP staff tested Mr Goddard for drugs regularly and conducted
room searches when indicated. He had tested positive for drugs and alcohol
throughout his stay at the AP (most recently on 10 November), but he had tested
negative in the days immediately before he collapsed. However, after Mr Goddard
was taken to hospital, staff noted that his attitude had changed in the days before
he went to hospital and wondered if he had been trying to bypass the new drug
testing system.
Information about drug tolerance at induction
57. Mr Goddard had a significant history of substance misuse. The risk of relapse for a
released prisoner with a history of substance misuse is high. Opioid dependence is
a chronic disorder with a high relapse rate, even after prolonged periods of
abstinence and a positive mindset. The risk of fatal overdose is also high as, after a
period of abstinence, opiate users are particularly vulnerable due to a diminished
tolerance, especially in the immediate post-release period.
58. The Approved Premises Manual says that staff should always discuss reduced drug
tolerance with residents at induction. We are concerned that staff did not discuss
the risk of reduced drug tolerance with Mr Goddard during his induction on 13
September. Although this probably made no difference in Mr Goddard’s case
because he had been in the community for 10 weeks before he collapsed, it could
make a critical difference in other cases. We raised the same concern following our
investigation into another drug-related death at Peterborough AP about two months
before Mr Goddard’s death. In response, the AP told us in March 2020 that a
discussion about reduced tolerance would form part of the induction for new
residents in future. We make the following recommendation:
The manager of Peterborough AP should provide assurances to the National
AP Team to update on measures taken to ensure that staff discuss residents
reduced tolerance to drugs during induction.
Naloxone
59. We are concerned that AP staff were not equipped to respond to opioid drug
overdoses at the time of Mr Goddard’s collapse. In November 2014, the World
Health Organisation published new guidelines about managing heroin overdoses in
the community. They recommended training first responders, including non-
medical first responders, to administer opiate antidotes, such as naloxone. We
recognise that staff having access to naloxone is unlikely to have changed the
outcome in Mr Goddard’s case, but it could be critical in other emergencies.
60. In response to a number of recommendations we made dating back to 2016, the
National Approved Premises Team produced a revised drug strategy which was
due to be implemented in 2020. This was delayed due to the COVID-19 pandemic,
but we are pleased that the National Probation Service has now rolled out the use
of naloxone in all APs, and that staff at Peterborough AP received their training in
July 2021.
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Emergency response and first-aid training
61. The National Probation Service’s Safe Working Practice document says that all AP
staff should be trained to give emergency first aid. Although we are satisfied that
AP staff acted promptly when they found Mr Goddard unresponsive, the residential
worker told us that she was not trained in first-aid.
62. A staff member told us that she took over as manager of the AP on 20 November
2019, three days before Mr Goddard was found unresponsive. She said that first
aid training is mandatory for all new AP staff and that she was aware that there was
a new untrained member of staff. She also said she had reviewed and scheduled
outstanding training for those who needed it. We have not therefore made a
recommendation about this.
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