David Lancaster

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr David Lancaster,
on 30 November 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
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 HMPPS in ensuring the standard of care received by
those within service remit is appropriate then our recommendations should be
focused, evidenced and viable. This is especially the case if there is evidence of
systemic process failures.
4. Mr David Lancaster died of hanging on 30 November 2022, following his release
from HMP Durham on 28 November. He was 42 years old. We offer our
condolences to those who knew him.
5. Mr Lancaster had a long history of offending. He had been in and out of prison for
various offences, including harassment and violence related offences. He
experienced depression and anxiety and was diagnosed with post-traumatic stress
disorder (PTSD). He had attempted suicide on several occasions while in the
community.
6. We are satisfied that there was little to indicate that Mr Lancaster was at heightened
risk of suicide in the time leading up to his death or that there was any specific risk
information that should have been shared between prison staff and his community
offender manager or support agencies.
7. We did not find any issues of concern.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
8. We were notified of Mr Lancaster’s death on 30 June 2023 (eight months after his
death). The prison was also informed on the same day, and we do not know the
reason for the delay.
9. The PPO investigator obtained copies of relevant extracts from Mr Lancaster’s
prison and probation records.
10. We informed HM Coroner for Hartlepool of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
11. The Ombudsman’s family liaison officer contacted Mr Lancaster’s next of kin to
explain the investigation and to ask if she had any matters she wanted us to
consider. She did not respond.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies in the report.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Durham
13. HMP Durham is a local prison, serving the courts of Tyneside, Durham and
Cumbria. It holds approximately 1,000 male prisoners. Spectrum Community Health
CIC provides primary healthcare services. Tees, Esk and Wear Valleys Foundation
NHS Trust provides mental health services.
Probation Service
14. 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
15. The most recent inspection of HMP Durham was in November 2021. Inspectors
reported that the quality of support delivered through Assessment, Care in Custody
and Teamwork (ACCT) case management for at-risk prisoners varied. Inspectors
also reported that contact between prison offender managers and prisoners was
poor, although release plans were of good quality.
Independent Monitoring Board
16. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 October 2022, the IMB
reported that prison offender manager clinics have started on each wing, to allow
prisoners direct access to offender managers.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
17. On 24 November 2021, Mr David Lancaster was sentenced to an 18-month
community order for harassment. The order was due to expire in May 2023.
18. In August 2022, Mr Lancaster secured a tenancy in Hartlepool, which remained his
address until his death. He had moved to Hartlepool to be closer to the support of
his family. In August, management of Mr Lancaster’s community order was
transferred to a community offender manager (COM). Mr Lancaster had diagnoses
of depression, anxiety and post-traumatic stress disorder (PTSD). He also told
probation staff that his brother had taken his life some years previously.
19. Mr Lancaster had a history of substance misuse. He had previously engaged with a
Drug and Alcohol Recovery Team (DART), attending regular sessions and
appointments to address his drug misuse via relapse prevention intervention.
During previous prison sentences, Mr Lancaster had engaged with substance
misuse services, including a Cocaine Anonymous course.
20. On 12 November, Mr Lancaster was remanded in custody to HMP Durham, on
charges of criminal damage and harassment. Prison staff started suicide and self-
harm prevention procedures (known as ACCT) as Mr Lancaster said that he had
attempted suicide a few months ago.
21. Mr Lancaster was not allocated a prison offender manager (POM), due to his
remand status. Probation staff confirmed that when Mr Lancaster was remanded to
Durham, his COM had no further contact with him.
22. On 13 November, Mr Lancaster attended an ACCT case review. Mr Lancaster said
that he was coping well in prison and that he felt safer and calmer in custody. He
stated he felt 'stupid' about his previous suicide and self-harm attempts and had no
current thoughts of them as he wanted to be there for his family. Mr Lancaster said
he had plans of working towards gaining access to his children and also working
while in prison and when released. Prison staff agreed to close the ACCT
procedures.
23. On the same day, a mental health nurse assessed Mr Lancaster. She recorded his
diagnoses and that he was prescribed antidepressants. (This prescription was
continued in prison.) The nurse concluded that Mr Lancaster had no current mental
health needs that required further input from the mental health team.
24. On 14 November, staff from the prison’s substance misuse service spoke with Mr
Lancaster as part of a non-clinical DART induction process. Mr Lancaster declined
to engage with them, stating he had no issues with drugs or alcohol. DART staff
discussed harm reduction with Mr Lancaster, which included risks of illicit substance
use, risks of reduced tolerance levels and overdose awareness. They made Mr
Lancaster aware of the self-referral process should he decide that he wished to
engage with their services.
25. On 23 November, Mr Lancaster met with a probation worker in prison. No issues
were raised throughout the session.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
26. On 28 November, Mr Lancaster attended a court appearance by video link. He was
convicted of criminal damage and harassment and received a suspended sentence
with a community order. Prison staff recorded that Mr Lancaster raised no issues or
concerns after this. He was released from custody that day.
Post-release
27. Probation informed us that Mr Lancaster’s release was not a standard release from
custody on licence, when there is an expectation of a first appointment on the day
of release, or the next working day. Mr Lancaster was released from remand to start
a suspended sentence order in which the requirement was to have an initial contact
within five working days of sentence. Therefore, Mr Lancaster would have had an
appointment by 5 December at the latest. However, due to Mr Lancaster’s death
very soon after release, there was no time for this to happen.
28. Mr Lancaster already had a sentence plan from his previous sentence in November
2021, which should have been reviewed within 15 days of the start of his new
sentence. Probation staff reported that the issues that needed work on Mr
Lancaster’s sentence plan included relationships, substance misuse and emotional
wellbeing/PTSD. Mr Lancaster was also supported by the mental health crisis team
who encouraged him to continue working with them for ongoing support.
Circumstances of Mr Lancaster’s death
29. Mr Lancaster was last seen at around 4.00am on 29 November, by a friend who
had not subsequently been able to contact him. On 30 November, Mr Lancaster’s
uncle visited his home address and found him hanging. Paramedics attended and
declared Mr Lancaster deceased.
Post-mortem report
30. The post-mortem report concluded that Mr Lancaster died of pressure on the neck
caused by hanging. The toxicology report found a level of cocaine in Mr Lancaster’s
blood in the range associated with fatality.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
31. Mr Lancaster had some risk factors for suicide and self-harm. He had previously
attempted suicide, he had a history of substance misuse, and he had been
diagnosed with anxiety, depression and PTSD. Mr Lancaster also described a
family history of suicide.
32. Probation staff told us that they identified that Mr Lancaster was at risk of self-harm,
including that he had threatened to take his life at the time of his offence.
33. Mr Lancaster had declined to engage with prison substance misuse services,
stating he had no current issues with drugs or alcohol.
34. Although he had these risk factors, we are satisfied that there was little to indicate
that Mr Lancaster was at heightened risk of suicide in the time before his release
from prison, or that there was any specific risk information that should have been
shared between prison and probation staff or support agencies.
Inquest
35. The inquest into Mr Lancaster’s death concluded on the 28 April 2024. The coroner
confirmed that Mr Lancaster died by suicide.
Adrian Usher
Prisons and Probation Ombudsman November 2024
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE