Daniel Evans

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Independent investigation into
the death of Mr Daniel Evans,
on 22 May 2024,
following his release from
HMP Stoke Heath
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 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 Daniel Evans died of acute kidney injury (non-traumatic), caused by an upper
gastrointestinal haemorrhage, on 22 May 2024 following his release from HMP
Stoke Heath on 16 May 2024. He was 39 years old. I offer my condolences to those
who knew him.
5. When Mr Evans’ community offender manager (COM) was on sick leave, his case
was not reallocated, which meant that referrals to arrange accommodation for him
were not completed and he was released homeless. However, given the staffing
pressures across the Probation Service and the recent policy change on timescales
for reallocating cases, we do not make a recommendation about this.
6. The clinical reviewer concluded that the clinical care Mr Evans received at Stoke
Heath was not of a good standard and was not equivalent to that which he could
have expected to receive in the community. She found that Mr Evans had a
diagnosed health condition which was not clearly documented or adequately
monitored. However, she concluded that this was not relevant to the cause of Mr
Evans’ death.
7. The clinical reviewer made four recommendations which were not related to Mr
Evans’ death but which the Head of Healthcare at Stoke Heath will want to address.
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The Investigation Process
8. Staffordshire and Stoke-on-Trent Coroner's Service notified us of Mr Evans’ death
on 3 June 2024. We have sent the Coroner a copy of this report.
9. The PPO investigator obtained copies of relevant extracts from Mr Evans’ prison
and probation records.
10. NHS England commissioned a clinical reviewer to review Mr Evans’ clinical care at
HMP Stoke Heath.
11. The investigator interviewed a Senior Probation Officer on 18 July 2024. She and
the clinical reviewer also interviewed four members of healthcare staff at Stoke
Heath on 12 and 13 August 2024.
12. The Ombudsman’s office contacted Mr Evans next of kin, his mother, to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond to our letter.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Background Information
HMP Stoke Heath
14. HMP Stoke Heath is a category C training and resettlement prison and young
offenders’ institution which holds convicted male prisoners. The healthcare provider
is Shropshire Community Health NHS Trust.
Probation Service
15. 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 which, 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
16. In April 2022, Mr Daniel Evans was convicted of drug offences and was sentenced
to two years and three months in prison. He was released on licence in November
2022 but was recalled to prison on 21 March 2023. He was released again on 3
April.
17. On 22 July, Mr Evans was recalled to HMP Altcourse, charged with possessing an
offensive weapon.
Pre-release planning
18. On 3 August 2023, Mr Evans was transferred to HMP Stoke Heath and attended an
initial health screen with a nurse. Mr Evans reported a history of drug misuse, so
she referred him to the substance misuse team who then saw him regularly.
19. On 8 August, Mr Evans’ Prison Offender Manager (POM) emailed Mr Evans’
Community Offender Manager (COM) to introduce herself.
20. On 11 August, the COM completed an assessment of Mr Evans’ risks and needs in
the community in preparation for his release. A Senior Probation Officer (SPO) told
us that a further assessment should be completed within 15 days of release, but Mr
Evans died before then.
21. On 14 August 2023, Mr Evans was sentenced to six months in prison for
possessing an offensive weapon.
22. On 18 August, the POM met Mr Evans for an initial interview. She remained in
regular digital communication with him throughout his time at Stoke Heath.
23. On 4 April, the COM went on long-term sick leave. She told us that she had planned
to complete accommodation referrals for Mr Evans before she went on sick leave
but had not managed to do so due to her large caseload. The SPO told us that due
to staffing pressures, Mr Evans’ case was not reallocated in his COM’s absence
and, therefore, accommodation referrals were not completed in preparation for Mr
Evans’ release.
24. On 23 April, Mr Evans did not attend an appointment with the pre-release clinic,
where he would have been supported to register with a GP practice.
25. On 25 April, a GP operating at Stoke Heath prescribed Mr Evans a month’s supply
of medication to ensure he had enough until he had registered with a community
GP.
26. On 7 May, the POM emailed the healthcare team, informing them of Mr Evans’
upcoming release date. A nurse referred Mr Evans to the community drug and
alcohol service.
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Release from HMP Stoke Heath
27. On 16 May, Mr Evans was released from Stoke Heath. He attended an induction
with a Probation Officer. He told her he was homeless. She asked if he wanted her
to contact the council, but he told her that it was ‘pointless’ and ‘a waste of time’. A
SPO told us that they were unable to complete a referral to the local authority for
accommodation because Mr Evans’ consent was needed. Mr Evans’ next
appointment was arranged for 23 May. (We do not know where Mr Evans lived on
release.)
28. On 19 May, Mr Evans went to A&E by ambulance after he had chest pain and
vomiting. The hospital treated him for a lower respiratory tract infection and
discharged him with a prescription.
29. On 21 May, Mr Evans returned to A&E and told hospital staff about his history of
abdominal pain, vomiting and black stools. He declined further assessment,
including a blood test, and discharged himself from hospital. He was deemed to
have mental capacity to make this decision.
Circumstances of Mr Evans’ death
30. On 22 May, Mr Evans went to A&E by ambulance for abdominal pain, vomiting and
black stools. He was referred to the acute medical team with a probable diagnosis
of upper gastrointestinal bleed. He was moved to the intensive care unit, where he
continued to deteriorate.
31. At 9.57pm that day, Mr Evans had a cardiac arrest and died.
32. On 23 May, the community substance misuse service phoned the Probation Service
to tell them that Mr Evans had died in hospital the previous day.
Post-mortem report
33. A hospital doctor established that Mr Evans died from acute kidney injury (non-
traumatic), caused by upper gastrointestinal haemorrhage. A post-mortem
examination was not carried out as the Coroner accepted the cause of death.
Inquest
34. At an inquest held on 3 June 2025, the Coroner concluded that Mr Evans died of
natural causes.
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Findings
Clinical Findings
35. The clinical reviewer concluded that the care Mr Evans received at Stoke Heath
before his release was not of a good standard and was not equivalent to that which
he could have expected to receive in the community. She found that Mr Evans had
a health condition (not related to the cause of his death) which was not clearly
documented or adequately monitored. The clinical reviewer made four
recommendations which were not related to Mr Evans’ death, but which the Head of
Healthcare at Stoke Heath will want to address.
Case reallocation in COM’s absence
36. Mr Evans’ COM went on long-term sick leave on 4 April 2024 and Mr Evans’ case
was not reallocated in her absence. This meant that accommodation referrals were
not completed for him, and Mr Evans was released homeless.
37. The SPO told us that at this time, the Probation Office was experiencing extreme
staffing issues and was operating as an Amber site (which meant that staff
workload was at over 110% across Staffordshire), and therefore high-risk cases
were prioritised. She told us that this meant it was not possible to reallocate all
cases and Mr Evans was not categorised as posing a high risk. She told us that the
usual practice was for cases to be reallocated when an officer had been off work for
more than six weeks. Mr Evans was released exactly six weeks after Ms Shaw went
on sick leave.
38. Since this time, changes have been made to the national Tiering and Case
Allocation Framework to introduce new timescales for the reallocation of cases
when a COM is absent from work. The policy states that if a COM is off work for
four weeks, the case should be reallocated. The SPO told us she learned of this
policy change on 19 July 2024.
39. Mr Evans’ POM told us that it was the COM’s responsibility to complete housing
referrals, and she was not made aware that the COM was on sick leave from work.
She also told us that since 1 July 2024, Stoke Heath’s pre-release team can now
also make accommodation referrals.
40. Although we recognise that Mr Evans died of natural causes, homelessness on
release from prison remains a significant challenge for HMPPS and partner
organisations in the community. Staffing pressures in the Probation Service are
widely recognised and there are no short-term fixes, although HMPPS has
introduced a number of actions to drive recruitment and improve the retention of
trained staff. In light of this, and due to the recent policy change, we make no
recommendation. However we note the impact overstretched services have on
HMPPS’s ability to prepare prisoners for release.
Adrian Usher
Prisons and Probation Ombudsman January 2025
Prisons and Probation Ombudsman 5
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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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