Daniel Hayfield

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Daniel Hayfield
on 8 February 2022, following
his release from HMP Durham
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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 Daniel Hayfield died of mixed drug toxicity on 8 February 2022, following his
release from HMP Durham on 4 February. He was 37 years old. We offer our
condolences to those who knew him.
5. We did not identify any issues relating to how prison or probation staff managed his
release, and we make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Hayfield’s death on 15 February 2022.
7. The PPO investigator obtained copies of relevant extracts from Mr Hayfield’s prison
and probation records. The investigation was then transferred to one of the
investigator’s colleagues.
8. We informed HM Coroner for Cumbria of the investigation. She gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
9. The Ombudsman’s family liaison officer contacted Mr Hayfield’s mother to explain
the investigation and to ask if she had any matters she wanted us to consider. Mr
Hayfield’s mother had no questions but asked for a copy of our report.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
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Background Information
HMP Durham
11. HMP Durham is a category B reception prison which holds up to 996 male prisoners
who have either been convicted or are on remand. It is managed by HMPPS. Tees
Esk and Wear Valley NHS Foundation Trust provide mental health services and
Humankind provide substance misuse services.
Probation Service
12. 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.
HM Inspectorate of Prisons
13. The most recent inspection of HMP Durham was in November 2021. Inspectors
reported Spectrum CIC provide clinical substance misuse services and Humankind
deliver psychosocial services, both are an integral part of the prisons drug strategy.
Despite some recruitment difficulties, prisoners still received good care. They also
reported that prisoners leaving prison were offered harm minimisation advice and
naloxone as necessary. The substance misuse services liaised with community
services to make sure there was effective discharge planning.
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Key Events
14. On 6 January 2022, Mr Hayfield was convicted of being in possession of a
controlled drug and was sentenced to two months in prison. He was sent to HMP
Durham.
15. When he arrived at Durham, a nurse completed Mr Hayfield’s first reception health
screen. Mr Hayfield said that he had overdosed in August 2021. Mr Hayfield also
said he had been prescribed 50ml methadone in the community but had been
taking illicit methadone at the same time, the last time being the previous day when
he took an extra 50ml of methadone, along with other illicit drugs. Mr Hayfield
tested positive for methadone, benzodiazepines and opiates. He was placed on a
20ml methadone detoxification programme and was monitored overnight. The
substance misuse team monitored Mr Hayfield daily until he was stable, and he was
then placed on a methadone care plan.
16. On 7 January, a practitioner from the substance misuse team discussed harm
reduction with Mr Hayfield and told him about the risks of using illicit drugs with his
methadone. As part of his methadone care plan, the clinical and non-clinical DART
team (drug and alcohol recovery team) liaised with the community treatment teams
in preparation for Mr Hayfield’s transition back to the community. Mr Hayfield was
referred to Recovery Steps Cumbria, a community substance misuse service, for
support once he was released.
17. That day, a GP at the prison completed a DART clinical review with Mr Hayfield. Mr
Hayfield said that he would occasionally smoke heroin, and take illicit Valium,
codeine and pregabalin tablets. The GP increased Mr Hayfield’s methadone dose to
50ml.
18. On 11 January, a resettlement officer completed Mr Hayfield’s basic custody
screening and he said that he would like support from the mental health team. She
made a referral that day.
19. The next day, a practitioner from the mental health team assessed Mr Hayfield. It
was noted that he had no mental health history, and no thoughts of suicide and self-
harm, so he was discharged from the service.
20. On 17 January, a nurse saw Mr Hayfield in the substance misuse clinic. Mr Hayfield
said that he felt anxious, worried and could not sleep at night, but he thought this
was due to his methadone dose. Mr Hayfield asked for his methadone to increase
by 10ml. She discussed this with the DART lead, who agreed to increase his
methadone to 60ml.
21. On 18 January, staff started suicide and self-harm prevention measures (known as
ACCT) because of their ongoing concerns about Mr Hayfield’s mental health, his
decline in mood and because he presented as confused and had started to isolate
himself.
22. The next day, a practitioner noted in Mr Hayfield’s medical record that he presented
with cognitive difficulties, was vacant when engaging and appeared unwell. She
also noted he had been seen by the EIP Team (Early Intervention in Psychosis) in
December 2021, but there was no psychosis documented and his behaviour could
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have been drug induced. Mr Hayfield was discharged from EIP, but they added him
to the urgent care pathway to be monitored. A member of the Integrated Support
Unit (the mental health wing) said that any prisoner who is allocated to the urgent
care caseload automatically have a ‘not for release (NFR)’ marker added to their
record, as a standard process. This allows the team to be made aware of anyone
being released, to ensure any prisoners that are unwell and in need of a Mental
Health Act assessment prior to release, are best supported and a clear plan put in
place.
23. Later that day, a practitioner from the mental health team completed a mental
health assessment as part of Mr Hayfield’s initial ACCT review. However, she was
not able to complete the assessment because of Mr Hayfield’s presentation at the
time.
24. On 21 January, a Supervising Officer (SO) closed the ACCT because his
presentation was better, and he said he had no thoughts of suicide or self-harm.
25. Later that day, Mr Hayfield tested positive for benzodiazepines (which he was not
prescribed). On 24 January, a nurse saw Mr Hayfield in the substance misuse
clinic, and he denied taking any illicit drugs in prison.
26. On 25 January, a practitioner noted that a nurse from the mental health team had
reviewed Mr Hayfield and believed that his presentation was likely to be related to
illicit substance use and not due to any acute mental illness. Following this review,
Mr Hayfield was discharged from the mental health team.
Pre-release planning
27. On 26 January, Mr Hayfield’s allocated community offender manager (COM) sent
his licence conditions to the prison. Mr Hayfield had two additional licence
conditions: to provide a urine or oral fluid sample at probation to test for any class A
or class B drugs and to attend Recovery Step Cumbria to address his dependency
on drugs. An initial appointment was arranged for Mr Hayfield to attend Recovery
Steps on 7 February.
28. On 1 February, a senior probation officer spoke with a social worker from the
mental health team at Durham. The senior probation officer wanted to know about
the NFR marker made on Mr Hayfield’s record. The social worker said that they
were unable to detain Mr Hayfield due to lack of mental health diagnosis, but that
they had found him temporary accommodation at a hotel following his release on 4
February.
29. The next day, a multi-disciplinary team meeting was held with the primary mental
health care team. It was noted that there was no evidence of psychosis, that Mr
Hayfield did not need a crisis follow up, and he did not need support from the
community mental health team. It was noted Mr Hayfield would benefit from a
talking therapies referral and counselling which he could access from his GP in the
community.
30. The resettlement officer completed a Duty To Refer (DTR- The Homelessness
Reduction Act 2017 requires prisons and probation services to refer anyone who is
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homeless or at risk of becoming homeless within 56 days to a local housing
authority) to Cumbria council.
31. On 3 February, the COM emailed the mental health team at Durham to gain more
information about their involvement with Mr Hayfield so that she could try and
engage him with services in the community. A nurse responded and said that Mr
Hayfield had been provided with accommodation in a hotel on release and that the
team were writing to his GP to recommend IAPT services (Improving Access to
Psychological Therapies - a programme for anxiety and depression), talking
therapies and counselling.
32. Later that day, a nurse supported Mr Hayfield with his housing assessment, with a
housing officer from Allerdale Council in Cumbria. The housing officer did not feel
Mr Hayfield was a priority and she provided Mr Hayfield with her contact details for
him to contact her when he was released the following day. There is no evidence
that Mr Hayfield called the housing officer following his release.
33. The substance misuse team at Durham had arranged an initial appointment for Mr
Hayfield with the Cumbria Drug and Alcohol Recovery Team, Recovery Steps
Cumbria, at their Workington office. The appointment was made for 7 February at
1:30pm, he was also told his prescription had been left at Moorclose Pharmacy for
him to collect on the 5 February.
34. On 4 February, Mr Hayfield was released from HMP Durham. He was released with
a naloxone kit (a medicine that rapidly reverses an opioid overdose).
Post-release planning
35. Mr Hayfield was released on a Friday and his licence conditions required him to
attend the West Cumbria probation office for his initial appointment at 2:00pm. Mr
Hayfield did not get to the probation office in time, so his COM provided him with an
appointment for the next working day, which was on Monday 7 February. He arrived
at the hotel accommodation found for him.
36. On 7 February, the COM completed Mr Hayfield’s initial appointment. She asked Mr
Hayfield what he had done over the weekend. Mr Hayfield seemed very confused
and said that he may have been in hospital due to taking an overdose. Mr Hayfield
said that he thought he had taken something but could not remember what or when.
She advised Mr Hayfield to attend Unity (a drug and alcohol recovery service -
providing treatment and recovery support for individuals affected by substance
misuse) that day, and to make an appointment with his GP. There is no evidence
that Mr Hayfield called his GP.
37. The COM told Mr Hayfield that she had spoken to the mental health in reach team
at Durham, who informed her they were making a referral to his local GP so Mr
Hayfield could access additional support in the community.
38. Later thar day, Mr Hayfield was due to meet his keyworker at 1.30pm at the
Recovery Steps Cumbria office. However, Mr Hayfield did not attend the
appointment. She attempted to call him on his mobile telephone, but he did not
answer. Mr Hayfield then attended the office at 4.00pm and saw her briefly. She
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gave Mr Hayfield her contact details and arranged another appointment. Mr
Hayfield died before next appointment.
Circumstances of Mr Hayfield’s death
39. On 8 February, the police informed HMPPS that Mr Hayfield had died.
40. At approximately 9.49pm, staff at the hotel where Mr Hayfield was living called an
ambulance after Mr Hayfield’s friend said that he had become drowsy and
unresponsive. Mr Hayfield was slumped in a chair and unresponsive when the
paramedics arrived. He was given three rounds of naloxone but remained
unresponsive and was taken to hospital, where it was confirmed that he had died.
Post-mortem report
41. The post-mortem report concluded that Mr Hayfield died of mixed drug toxicity,
principally codeine but in combination with methadone, diazepam, flualprazolam,
pregabalin and cocaine.
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Findings
Mental health services
42. The mental health team worked with Mr Hayfield during his time in prison. They
assessed Mr Hayfield appropriately and discussed his needs at the multi-
disciplinary meetings. The team offered support and additional monitoring as
required. Following a mental health needs assessment, it was decided that Mr
Hayfield did not need any further intervention from the mental health team, and he
was discharged from the service, but they referred him to talking therapies and
counselling in the community and he was appropriately referred to his GP.
Substance misuse services
43. The substance misuse team at Durham monitored and engaged with Mr Hayfield
during his time in prison. He was advised of the dangers of using illicit substances,
was released with a naloxone kit, and was appropriately referred to the community
substance misuse team, Recovery Steps Cumbria.
Adrian Usher
Prisons and Probation Ombudsman April 2024
At the inquest held on the 18 July 2024, the coroner concluded that Mr Hayfield died of
drug related causes.
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