Daniel Woods

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Independent investigation into
the death of Mr Daniel Woods,
on 23 June 2024,
following his release from
HMP Cardiff
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, 2026
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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 investigated 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 Woods died from multiple injuries on 23 June 2024, after he fell from the
Clifton Suspension Bridge in Bristol, following his release from HMP Cardiff three
days earlier. Post-mortem toxicology tests detected a slightly raised level of
methadone and low levels of heroin and cocaine in his system. He was 37 years
old. We offer our condolences to Mr Woods’ family and friends.
5. The support Mr Woods received from Cardiff’s mental health and substance misuse
services was good. He was told how to access services if he was in crisis and a
mental health nurse saw him regularly. Mr Woods had community mental health
provision in place for his medication on release and after his release, he was
referred to community substance misuse services but died before he could access
them. Communication between Mr Woods’ prison offender manager and community
offender manager was poor, despite the community offender manager’s attempts to
make contact. However, this ultimately did not affect Mr Woods’ pre-release
planning because he already had mental healthcare provision in place in the
community. We do not make any recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Woods’ death on 19 July 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr Woods’ prison
and probation records.
8. We informed HM Coroner for Bristol 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 Woods’ mother to explain the investigation
and to ask if she had any matters she wanted us to consider. She had the following
questions which we have tried to answer in this report:
• Was HMP Cardiff aware of Mr Woods’ mental health issues?
• Why was Mr Woods released at such short notice?
• Why was there no release or care package in place?
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Woods’ family received a copy of the draft report. The solicitor representing Mr
Woods’ family wrote to us raising a number of issues and questions 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 Cardiff
12. HMP Cardiff is a category B reception and resettlement prison which holds male
prisoners. Physical and mental healthcare services are provided by Cardiff and Vale
University Health Board, and the substance misuse service is provided by Dyfodol.
Probation Service
13. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriate. Post-release, the Probation Service supervises people throughout their
licence period and post-sentence supervision.
End of Custody Supervised Licence scheme
14. The End of Custody Supervised Licence scheme was in operation from October
2023 to September 2024 and allowed certain determinate sentenced prisoners to
be released before their conditional release date. At the start of the scheme, it
allowed for prisoners in certain prisons to be released a maximum of 18 days before
their conditional release date. This was increased to a maximum of 35 days on 8
March 2024 and on 23 May, to a maximum of 70 days early.
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Key Events
Background
15. On 10 May 2024, Mr Daniel Woods was convicted of theft and criminal damage and
was sentenced to 18 weeks in prison. He was sent to HMP Cardiff.
16. During his initial health screen in reception, he told healthcare staff that he had a
history of self-harm, and had last harmed himself three years ago. He said he had
no current thoughts of self-harm. He told healthcare staff that he had paranoid
schizophrenia and schizoaffective disorder, for which he was prescribed
paliperidone which he received by depot injection. Mr Woods also told them that he
had used heroin daily and was withdrawing. He was prescribed methadone (an
opiate substitute to relieve the symptoms of withdrawal).
17. On 11 May, Mr Woods was referred to the mental health team to discuss his
schizophrenia. Mr A, an occupational therapist, saw him and told him how to access
mental health support. Mr Woods told Mr A that he had no thoughts of suicide or
self-harm.
18. On 13 May, Mr Woods met the prison resettlement team. He told them that he had
substance misuse issues and was prepared to engage with Dyfodol while in prison.
That day, the substance misuse team saw him for an induction, and referred him to
Bristol Criminal Justice Intervention Team for community support once released. He
was given harm minimisation advice and added to their caseload.
19. On 14 May, Ms A, Mr Woods’ Community Offender Manager (COM), emailed Mr B,
his Prison Offender Manager (POM), to ask if he was receiving support or
medication for his mental health. She did not receive a response.
20. On 16 May, Nurse A, a mental health nurse, contacted the Speedwell Centre (an
NHS community mental health service), where Mr Woods received his medication
for schizophrenia while in the community. They said that they saw Mr Woods to
administer his medication in the community but he did not engage well with them
otherwise.
21. On 20 May, Mr Woods saw Nurse A and told her he felt well and had no thoughts of
suicide and self-harm. She told him that his next paliperidone injection was due in
July, and that they would contact his community psychiatric nurse if he was
released before then. He was kept on the prison mental health team’s caseload.
22. On 5 June, Nurse A saw Mr Woods again. He said he had no thoughts of suicide or
self-harm. Nurse A noted that an officer on the landing was concerned about Mr
Woods’ presentation but a nurse had not noticed any unusual behaviour while
taking his bloods and carrying out a routine check of his heart. She told the
investigator that officers only raised concerns that he did not engage with staff and
kept to himself. She said Mr Woods had engaged in conversation but had not
expressed any mental health concerns. That day, Mr Woods tested negative for
drugs.
23. On 7 June, Ms A emailed Mr B to discuss Mr Woods’ referral to Community
Accommodation Service 2 (CAS2, which provides prison leavers with short-term
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accommodation) for accommodation post-release and his home detention curfew (a
scheme which allows prisoners to be released early to a suitable address, subject
to a curfew). She did not receive a response.
24. On 11 June, during a pre-release interview, Mr Woods told the resettlement team
that he had not engaged with the prison’s substance misuse service. The next day,
he said he did not need substance misuse intervention in the community.
25. On 17 June 2024, Ms A emailed Mr B again about Mr Woods’ accommodation and
his application for early release. Mr B responded with an update about his
application and his CAS2 referral which was with the prison.
26. On 18 June, Mr Woods was given his release appointments, harm minimisation and
overdose awareness advice given his reduced tolerance to drugs post-custody. His
resettlement officer emailed Ms A to tell her that he had not been accepted by
Community Accommodation Service 3 (CAS3, which provides prison leavers with
up to 84 days of temporary accommodation).
Release from HMP Cardiff
27. On 20 June, Mr Woods was released early from Cardiff under the End of Custody
Supervised Licence scheme. Mr Woods was not being monitored under suicide and
self-harm prevention procedures and did not appear in crisis when he was released.
He was given harm minimisation advice about his reduced tolerance to drugs and a
naloxone kit (a medication that can reverse the effects of an opioid overdose). He
was already under the care of the Speedwell Centre so did not need to be referred
to an additional community mental health service. That day, Nurse A emailed Mr
Woods’ care co-ordinator at the Speedwell Centre, and outlined his behaviour in
custody, an update on his housing and when his next injection was due.
28. Mr Woods reported to the probation office on the day of his release. Ms A noted
that he appeared lethargic and was sweating, and asked him if he had been using
illicit drugs in custody. He stated he had not. They discussed his mental health. Mr
Woods told her that he had been given mental health medication on release.
29. As Mr Woods was released before a CAS2 bedspace was made available, he did
not have accommodation. Ms A told him that he needed to go to the local authority
and refer himself for accommodation. At 4.20pm, the local authority emailed Ms A
and confirmed that he had presented and they had given him emergency
accommodation. They had also referred him for permanent accommodation.
30. On 21 June, Ms A referred Mr Woods to Developing Health and Independence
(DHI, a charity that provides support services including to address substance
misuse) to receive psychosocial intervention. Ms A told the investigator that Mr
Woods was known to DHI as he was a prolific drug user, and he knew how to
access their support.
31. That day, Dyfodol arranged an appointment with Bristol Drugs Project for Mr Woods
to receive a methadone prescription. As Bristol Drugs Project was not offering
prescribing appointments, they made an appointment for him to receive his
methadone at another medical centre that day. However, Mr Woods did not attend
this appointment.
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Circumstances of Mr Woods’ death
32. On 23 June 2024, police received a call from a member of the public who had seen
someone fall from the Clifton Suspension Bridge in Bristol. The police, ambulance
and fire services attended the scene. Mr Woods was found on the canopy below the
bridge, with injuries consistent with a fall from height. The paramedics confirmed life
extinct at 3.15pm.
Post-mortem report
33. The post-mortem report concluded that Mr Woods died from multiple injuries. The
Coroner noted that Mr Woods was suspected to have fallen from the Clifton
Suspension Bridge and his injuries were consistent with a fall from height. Post-
mortem toxicology tests detected a slightly raised level of methadone and low levels
of heroin and cocaine, consistent with recent recreational drug use. The Coroner
noted that it was difficult to quantify the effect of recreational drug use on Mr
Woods’ behaviour, especially in the context of Mr Woods’ diagnosis of paranoid
schizophrenia.
Inquest
34. At an inquest held on 12 January 2026, the Coroner concluded that Mr Woods died
of multiple injuries consistent with a fall from height.
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Findings
Support from mental health and substance misuse services
35. Mr Woods died from multiple injuries, consistent with falling from a bridge.
Witnesses told the police they saw a “body falling from the Clifton Suspension
Bridge”. We cannot establish the exact circumstances of his death. However, the
Coroner noted in the post-mortem report that no suspicious circumstances had
been identified or a second or third party implicated in Mr Woods’ death. Although a
slightly raised level of methadone and low levels of heroin and cocaine, consistent
with recreational use, were detected in Mr Wood’s post-mortem toxicology results,
the Coroner noted that it was difficult to quantify the effect of recreational drug use
on Mr Woods’ behaviour, particularly in the context of his diagnosis of paranoid
schizophrenia.
36. Mr Woods’ mental health was well managed while in prison: Nurse A, his allocated
mental health nurse, saw him regularly and he was prescribed medication to
manage his mental health issues. While he reported a history of self-harm on arrival
at Cardiff, he was not considered at raised risk of suicide or self-harm during his
time there and was not subject to suicide and self-harm monitoring procedures at
any point.
37. Nurse A appropriately contacted his community care co-ordinator on the day of his
release to provide a handover about Mr Woods’ care needs. This provided good
continuity of mental healthcare as he transitioned into the community and no
referrals were needed as he remained under the care of the Speedwell Centre, who
were also due to prescribe him his next paliperidone injection. We are satisfied that
the prison mental health team ensured that Mr Woods had mental health treatment
and support in place for when he was released into the community.
38. Mr Woods saw the substance misuse service for his methadone prescription while
in prison. He was tested for drugs once while in custody, and the result of this was
negative. Mr Woods declined to engage with the prison’s substance misuse service.
However, Ms A appropriately referred him to community substance misuse
services. Although she did this the day after his release and it would have been
better if the referral had been made earlier, she told us that Mr Woods had
consistently not engaged with substance misuse services in the community.
Although Mr Woods was released early, overall, his pre-release planning and post
release supervision was appropriately completed and was not affected by his early
release.
Communication between prison and community offender managers
39. Communication between a POM and COM is important in pre-release planning. A
handover of information from the POM to the COM is part of the transfer of
responsibility for a prison leaver and should be carried out before his release. The
role of the POM is to identify and address factors that contribute to reoffending such
as substance misuse or mental health needs. Where there are complex needs, it is
a POM’s responsibility to relay this to the COM when a prison leaver is released.
Ms B, the Head of Offender Management Delivery, told the investigator that while
there is no set guidance for POM to COM contact in short-term sentences like Mr
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Woods’, she would expect to see contact throughout the sentence and leading up to
release, with the level of contact based on individual needs.
40. Ms A told the investigator that she knew Mr Woods had a diagnosis of paranoid
schizophrenia but he did not want to discuss it and did not give her his consent to
contact healthcare professionals in the community. Ms A tried to contact Mr B
several times by email before Mr Woods’ release to obtain information about his
mental health. Mr B did not respond to her and could not recall why. While we
recognise that Mr Woods would have received his medication from the Speedwell
Centre in the community, Mr B should have given Ms A a full handover about Mr
Woods’ risks and needs, especially given his complex mental health needs. This
would have enabled her to better support him in the community. Ms A told the
investigator that she could not contact Mr B through any other means than email as
she did not have his phone number. While we recognise that Mr B’s phone number
was not listed in his email signature in the chain of emails between them, she could
have reached him by phone by contacting the prison or by Microsoft Teams.
Although Mr Woods was already under the care of a community mental health
service, had this not been the case, the lack of communication between the COM
and POM might have caused a delay in the pre-release planning and resulted in
him not receiving mental health or substance misuse support on release.
Adrian Usher
Prisons and Probation Ombudsman September 2025
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