Darren Stokes

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Independent investigation into
the death of Mr Darren Stokes,
on 16 May 2023, 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, 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 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 Darren Stokes died when he was struck by a moving train on 16 May 2023,
following his release from HMP Cardiff on 4 May. He was 40 years old. We offer our
condolences to those who knew him.
5. Mr Stokes was in Cardiff for only three weeks on remand and was released when
the criminal charges against him were dropped. He was therefore not under
probation supervision when he died.
6. We make no recommendations.
Prisons and Probation Ombudsman 1
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The Investigation Process
7. HMPPS notified us of Mr Stokes’ death on 18 July 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Stokes’ prison
and probation records.
9. The investigator interviewed one member of staff by video call on 2 September
2024.
10. We informed HM Coroner for Reading of the investigation. They gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
11. The Ombudsman’s office contacted Mr Stokes’ father to explain the investigation
and to ask if he had any matters he wanted us to consider. He had no questions but
asked for a copy of the report.
12. We shared our initial report with HMPPS. They found no factual inaccuracies.
13. We sent a copy of our initial report to Mr Stokes’ father. He did not notify us of any
factual inaccuracies.
2 Prisons and Probation Ombudsman
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Background Information
HMP Cardiff
14. HMP Cardiff holds remand and sentenced men, many of whom arrive from local
courts. Cardiff and Vale University NHS Health Board provides primary physical and
mental health services. Psychosocial substance misuse support is provided by
Dyfodol integrated partnership services.
Probation Service
15. 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
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
Prisons and Probation Ombudsman 3
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Key Events
Background
16. On 13 April 2023, Mr Darren Stokes was remanded in custody for an alleged
harassment offence. He was sent to HMP Cardiff.
17. Mr Stokes told staff he had no mental health concerns and no substance misuse
issues. He declined support from the mental health team. Dyfodol, the substance
misuse service at Cardiff, provided Mr Stokes with harm minimisation advice but he
declined any further support.
18. On 17 April, a resettlement worker saw Mr Stokes and asked him if he needed help
with housing upon release. Mr Stokes did not engage. The resettlement worker
added Mr Stokes to the Homeless Persons Spreadsheet (a tool used to keep track
of prisoners who are due to be released and may be at risk of homelessness).
19. On 19 April, the healthcare team at the prison received an email from the Homeless
Person’s Outreach team, which set out Mr Stokes’ history of substance misuse,
mental health concerns and homelessness.
20. The same day, staff discussed Mr Stokes at the in-reach mental health referral
screening and added him to the waiting list to be assessed (with a standard target
time of 28 days).
Release from HMP Cardiff
21. On 4 May, Mr Stokes was released from Cardiff as the charges against him were
dropped. He was released homeless. He was not subject to probation supervision.
22. On the day of his release, the prison emailed the outreach team informing them of
Mr Stokes’ release from Cardiff.
Circumstances of Mr Stokes’ death
23. On 16 May, Mr Stokes was struck by a moving train approximately three quarters of
a mile from Pangbourne Railway Station. The train driver said a man ran in front of
the train and no one else was involved.
Post-mortem report
24. The post-mortem report concluded that Mr Stokes died from multiple injuries.
Toxicology tests showed likely amphetamine use prior to his death which may have
had an effect on his decision making/cognitive function.
4 Prisons and Probation Ombudsman
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Findings
25. It is unclear if Mr Stokes’ death was intentional or accidental. He gave no indication
to prison staff that he was at risk of suicide, and he raised no concerns with staff
regarding his mental health or emotional wellbeing. The prison notified the
community outreach team of his release.
26. Mr Stokes was released because the charges against him were dropped. As he
was not convicted of any offences, he was not under probation supervision when
released on 4 May.
27. Mr Stokes was released homeless. He refused to engage with the resettlement
worker when she saw him on 17 April, and then he was released unexpectedly on 4
May, so no housing referrals were done.
28. Since Mr Stokes’ death, Cardiff have introduced a resettlement pack which provides
information to prisoners on what to do if they are released homeless and signposts
them to services. The pack also includes information on substance misuse services.
Prisoners are given the resettlement pack even if they do not engage with the
resettlement team.
29. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman February 2025
Inquest
At the inquest, held on 11 March 2025, the Coroner concluded that against a background
of recreational drug use and mental health issues, Mr Stokes died as a result of fatal
injuries sustained from placing himself in the way of a train.
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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