David Stead

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr David Stead,
a resident at Box Tree Cottage
Approved Premises,
on 9 March 2025
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, 2026
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. 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.
3. Mr David Stead died from the toxic effects of cocaine and psychoactive substances
(PS) on 9 March 2025, while he was a resident at Box Tree Cottage Approved
Premises (AP). He was 37 years old. We offer our condolences to those who knew
him.
4. Mr Stead was released from HMP Wealstun to Box Tree Cottage AP on 27
February. He received good support from substance misuse services at Wealstun.
They warned him about the risks of overdose and appropriately referred him to
community drug and alcohol services prior to his release.
5. Mr Stead spent around one week at Box Tree Cottage AP. While he gave several
positive alcohol breath tests, there were no suspicions that he was using drugs
while he was at the AP.
6. We make no recommendations.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
7. HMPPS notified us of Mr Stead’s death on 10 March 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Stead’s prison
and probation records.
9. We informed HM Coroner for West Yorkshire of the investigation. They gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
10. The Ombudsman’s office contacted Mr Stead’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. She asked for her
son’s cause of death. This has been answered in the report.
11. We shared our initial report with HMPPS. They found no factual inaccuracies.
12. We sent a copy of our initial report to Mr Stead’s mother. She did not notify us of
any factual inaccuracies.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
Box Tree Cottage Approved Premises
13. Approved premises (APs) previously known as probation and bail hostels,
accommodate offenders released from prison on licence and those directed there
by the courts as a condition of bail. Their purpose is to provide an enhanced level of
residential supervision in the community, as well as a supportive and structured
environment.
14. Box Tree Cottage AP in Bradford, West Yorkshire, accommodates 17 male
residents and provides activities tailored to meet individual needs to minimise the
risk of reoffending. A key worker is allocated to each resident to oversee their
progress and wellbeing and to help them adhere to licence conditions and the AP
rules. Staff are on duty 24 hours a day to monitor residents' behaviour and report to
their community offender manager.
HMP Wealstun
15. HMP Wealstun is a category C adult training and resettlement prison for men.
Practice Plus Group provides physical and mental health care services. Midlands
Partnership NHS Foundation Trust provides substance misuse services.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
Background
16. In June 2018, Mr David Stead was sentenced to eight years in prison for wounding
with intent to endanger life.
17. Mr Stead had diagnoses of borderline personality disorder (a condition that affects
how you think, feel and interact with other people and is characterised by unstable
personal relationships, poor self-image, low mood and impulsive behaviour) and
obsessive-compulsive disorder (a mental health condition characterised by
recurrent, unwanted thoughts (obsessions) and/or repetitive behaviours
(compulsions)). He had periods of anxiety, depression, self-harm and suicide
attempts. Mr Stead also had type 1 diabetes.
18. Mr Stead had a long history of drug use in the community. Although he said he
stopped taking drugs several years prior to sentencing, probation records show
intermittent relapses into crack cocaine use which were attributed to a decline in his
mental health. Records also note that Mr Stead began drinking alcohol at the age of
12, with his dependence worsening progressively over time. He used alcohol as a
form of self-medication and a coping mechanism, and alcohol was a significant
contributing factor in the commission of his offence.
19. Mr Stead was released from prison to an Approved Premises (AP) in August 2021
but was recalled three months later after he tested positive for cocaine, used
alcohol and took an overdose.
20. On 15 January 2024, Mr Stead was released again. The next day, he was recalled
to prison for breaching his licence conditions due to alcohol use. He was sent to
HMP Leeds where he completed an alcohol detoxification programme and on 23
January, he was moved to HMP Wealstun.
Pre-release planning
21. When Mr Stead arrived at Wealstun, he told a nurse that he did not currently have
any problems with drugs or alcohol and did not want to be referred for substance
misuse support at Wealstun.
22. On 17 July, Mr Stead attended an initial substance misuse assessment following a
self-referral for substance misuse support. He told his recovery worker that he had
been taking psychoactive substances (PS) but had recently moved to a new wing,
had not taken drugs for six days and wanted a ‘new start’. The recovery worker
warned Mr Stead about the risks associated with taking drugs and gave him advice
to minimise the risk of overdose, which included not using drugs by himself and only
using small amounts to test their strength. She also warned Mr Stead about the
dangers of mixing drugs with alcohol and how this could further increase the risk of
overdose. The recovery worker gave Mr Stead information on tolerance levels and
overdose awareness, including how to recognise the signs and symptoms of an
overdose, and what to do in the event of one. They agreed on a care plan in which
Mr Stead would have monthly 1:1 structured SMS counselling, and Mr Stead was
given in-cell workbooks to complete around relapse and recovery.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
23. On 13 August, Mr Stead attended his monthly substance misuse counselling
appointment. Mr Stead said that he drank alcohol as a way of coping and to give
him confidence in social situations. He told the recovery worker that he had realised
he was unable to drink in moderation and must stop drinking completely. He said
that once released from prison, he would need to avoid certain people and
situations to avoid the temptation of drinking. His recovery worker noted that Mr
Stead engaged well, had completed all workbooks to a high standard, and showed
a good understanding of the issues surrounding his substance misuse.
24. Over the next five months, Mr Stead attended his monthly SMS counselling
appointments which focused on his alcohol use and alternative coping strategies to
self-harm. It is noted that he engaged positively in all appointments and during this
time, he also completed workbooks on alcohol, cocaine, wellbeing and mindfulness,
and sleep hygiene.
25. On 15 January 2025, Mr Stead attended his parole hearing with the Parole Board
(who decide whether a prisoner is suitable to be released from prison after serving
the minimum portion of their sentence). The next day, Mr Stead received notification
from the Parole Board that he was suitable for release. He was given a release date
of 27 February.
26. On 4 February, Mr Stead told his recovery worker that he was feeling anxious about
his upcoming release from prison and was worried about relapsing into alcohol use.
He was scheduled to be released on an alcohol monitoring tag and had already
been referred to Reconnect (a service that assists individuals transitioning from
custody to community-based health and support networks) as well as The
Discovery Project, which provides support for substance use and mental health. In
response, the recovery worker gave Mr Stead contact information for Bradford New
Vision, a local drug and alcohol support service, along with a list of nearby
Alcoholics Anonymous groups.
27. On 12 February, Mr Stead’s prison offender manager (POM) sent him details of an
upcoming pre-release planning videolink appointment with his community offender
manager (COM), scheduled for 19 February.
28. On 19 February, Mr Stead saw his POM who reviewed his discharge paperwork
with him and went through the conditions of his licence. The POM reminded Mr
Stead that he had a videolink appointment with his COM at 12.30pm that afternoon.
Mr Stead did not attend.
Release from HMP Wealstun
29. On 27 February, a nurse saw Mr Stead prior to his release and gave him a seven-
day supply of discharge medication. He was released from Wealstun at around
10.00am. The prison notified probation (the COM and the AP) that Mr Stead had
been monitored using suicide and self-harm prevention procedures (known as
ACCT) shortly before leaving prison and therefore may need additional support on
his release.
30. At approximately 4.00pm, Mr Stead attended Box Tree Cottage Approved Premises
(AP) as instructed. When he arrived, he said that he was feeling positive about
being in the AP. He said his recent acts of self-harm were a coping mechanism
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
while in prison, and that he was unlikely to self-harm now that he had been
released. As part of the AP induction process, an AP residential worker spoke to Mr
Stead about his risk factors for suicide and self-harm and when these might be
increased. Mr Stead said that he was at greater risk during periods of deteriorating
mental health and when drinking alcohol. Together, they developed a support plan
outlining strategies to help him maintain his safety, identifying individuals he could
turn to for support, and specifying how AP staff could help during times of need.
Due to his recent history of self-harm, Mr Stead was subject to additional welfare
checks while residing at the AP.
31. At 9.00am the next morning, Mr Stead attended his first AP key work session with
his allocated key worker. Mr Stead was due to have an alcohol monitoring tag fitted
that morning however, due to having swollen ankles (a symptom of his diabetes),
the tagging company said that Mr Stead required a letter from his GP before the tag
could be fitted. As Mr Stead was not yet registered with a GP, the key worker
registered him with a local GP surgery. Mr Stead was not permitted to have the
medication for his mental health in possession whilst residing at the AP. However,
he was permitted to have his insulin pen (for diabetes) in his possession when
leaving the premises. The key worker reminded Mr Stead of the importance of
taking his insulin pen with him when leaving the premises, especially as he needed
to take the medication every day at around 11.30am.
32. At 10.00am, Mr Stead attended his induction at Bradford Probation Office. His COM
completed his induction, went through his licence conditions, and encouraged Mr
Stead to comply with the AP rules. This included reiterating that Mr Stead must
abide by his 7.00pm curfew and was not permitted to drink alcohol. A support
worker from Reconnect was present and told Mr Stead about local support services
available to him. The COM issued Mr Stead with his next probation appointment for
7 March at 10.00am.
33. When he returned to the AP at around 2.30pm, Mr Stead completed a routine
alcohol breath test. This showed as positive for alcohol consumption. Mr Stead
again left the AP and returned at around 4.30pm, when he gave another positive
alcohol breath test. An AP residential worker relayed this information to Mr Stead’s
COM. Mr Stead took his insulin as prescribed and complied with the conditions of
his curfew.
34. Over the next two days, Mr Stead took all his medications as prescribed, was
present for his curfew, and raised no concerns during his welfare checks. On both
days however, Mr Stead gave positive alcohol breath tests. His COM was informed
of this.
35. On 3 March during a key work session, Mr Stead told his AP worker that he had not
self-harmed since his release from prison and although he was drinking alcohol, he
was trying to reduce this daily. The key worker reminded Mr Stead that he needed
to request a letter from his GP to enable him to have his alcohol monitoring tag
fitted, which Mr Stead agreed to do. Mr Stead raised no concerns that day and took
his medication as prescribed. At around 6.00pm that evening, Mr Stead gave a
positive alcohol breath test.
36. Over the next few days, Mr Stead gave multiple positive alcohol breath tests,
although the tests showed a gradual reduction in the amount of alcohol consumed.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
37. On the morning of 7 March, Mr Stead left the AP to attend his appointment at
Bradford Probation Office. Shortly after leaving, Mr Stead telephoned the AP to let
them know he was having pain in his legs and did not feel able to get to his
appointment. He returned to the AP and gave a positive alcohol breath test. An AP
residential worker relayed this information to the COM, and the COM rearranged
the appointment for 10 March at 10.00am.
38. The next morning, Mr Stead took his medication as prescribed and was present for
his morning welfare checks. Later that afternoon, Mr Stead left the AP.
39. At 7.00pm, Mr Stead failed to meet his curfew as he had not returned to the AP. An
AP residential worker phoned him but he did not answer. Over the next few hours,
AP staff sent Mr Stead multiple text messages and tried to contact him on his
mobile phone, but he did not answer. A residential worker contacted Bradford Royal
Infirmary Hospital as well as West Yorkshire Police, however both said they had not
had contact with Mr Stead.
40. At 9.00pm, Mr Stead had still not returned to the AP, so the AP manager initiated
emergency recall procedures.
Circumstances of Mr Stead’s death
41. On the afternoon of 9 March, a member of the public found Mr Stead unresponsive
on City Road in Bradford. Paramedics attended and pronounced life extinct at
3.30pm.
Post-mortem report
42. The post-mortem report concluded that Mr Stead died from cocaine and MDMB-
4en-PINACA (a synthetic cannabinoid) intoxication.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Substance misuse support
43. Mr Stead initially said he did not require support from SMS when he arrived at
Wealstun. However, around six months later, he self-referred and admitted to using
PS. He continued to engage with SMS during the rest of his time at Wealstun. He
received monthly SMS counselling and was warned about the dangers of drug use,
reduced tolerance levels and risk of overdose.
44. Shortly before his release from Wealstun, Mr Stead told his recovery worker that he
was worried he would relapse into drug and alcohol use in the community. He was
referred to community services to help with the transition and provide substance
misuse and mental health support. The recovery worker also gave Mr Stead
information about a local drug and alcohol support service, along with a list of
nearby Alcoholics Anonymous groups.
45. We consider that Mr Stead received good support with his drug and alcohol issues
at Wealstun and was appropriately referred to community services prior to his
release.
46. There were no indications that Mr Stead was using drugs while he was at Box Tree
Cottage AP. However, he gave several positive alcohol breath tests at the AP. He
told staff that he was drinking daily but reducing the amount each day. This was
supported by the alcohol breath test results which showed a gradual reduction in
the amount of alcohol consumed. Given that Mr Stead admitted his alcohol use and
was reducing it, together with his health issues and the inability to fit his alcohol
monitoring tag, we can understand why he was not recalled at that time.
47. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman November 2025
Inquest
At the inquest, held on 11 February 2026, the Coroner concluded that Mr Stead’s death
was drug related.
8 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