Dean Sheppard

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Independent investigation into
the death of Mr Dean Sheppard,
on 25 December 2023, following
his release from HMP Stoke
Heath
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, 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 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 Dean Sheppard died from Influenza A (a viral infection also known as swine flu)
on 25 December 2023, following his release from HMP Stoke Heath on 21
December 2023. He was 48 years old. We offer our condolences to those who
knew him.
5. Mr Sheppard was released with accommodation in place. We found that the
appropriate accommodation referrals to homelessness support services were made.
6. We found that Mr Sheppard accessed satisfactory support with his substance
misuse issues at Stoke Heath. Substance misuse support was also put in place
when he was released from prison.
7. Mr Sheppard did not report any concerns about his physical health. He was
assessed by healthcare in the days leading up to, and on the day of his release and
did not present as physically unwell. The clinical reviewer found that the care Mr
Sheppard received at Stoke Heath was equivalent to that which he would have
received in the community. The clinical reviewer made one recommendation, which
did not impact on her assessment of equivalence, that the Head of Healthcare will
wish to address.
8. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Sheppard.
9. We make no recommendations.
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The Investigation Process
10. HMPPS notified us of Mr Dean Sheppard’s death on 5 January 2024.
11. The PPO investigator obtained copies of relevant extracts from Mr Sheppard’s
prison and probation records.
12. The investigator interviewed Mr Sheppard’s community offender manager on 25
March 2024.
13. We informed HM Coroner for Birmingham of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
14. The Ombudsman’s office contacted Mr Sheppard’s mother and sister to explain the
investigation and to ask if they had any matters they wanted us to consider. They
asked questions relating to pre-release planning, methadone dosage and post-
release travel arrangements. They also had concerns relating to Mr Sheppard’s
healthcare at Stoke Heath. Their concerns have been addressed in this report, the
clinical review and in separate correspondence.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
16. Mr Sheppard’s family received a copy of the draft report. They raised a number of
issues 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 Stoke Heath
17. HMP Stoke Heath is a category C prison which holds convicted and remanded male
prisoners. Shropshire Community Health NHS Trust provide primary health services.
North Staffordshire Combined NHS Trust provides secondary health services and
substance misuse treatment. Forward Trust provides non-clinical substance misuse
services. Nursing cover is available between 7.30am and 7.30pm seven days a
week.
Probation Service
18. 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.
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Key Events
Background
19. On 31 August 2023, Mr Dean Sheppard was convicted of theft and sentenced to nine
months in prison. At the time of sentencing, Mr Sheppard was subject to a
community order for shoplifting, which was revoked. He was sent to HMP
Birmingham.
20. At his initial health screen, Mr Sheppard told a nurse that he had a history of
substance misuse and poor mental health. He said that he had been drinking alcohol
daily and used drugs in the community. Mr Sheppard tested positive for cocaine,
cannabis, opiates and benzodiazepines (medication that slows down brain activity,
used for anxiety and mental health conditions). He was prescribed methadone,
diazepam (used to treat anxiety and alcohol withdrawal) and other medication to
lessen his withdrawal symptoms from alcohol.
21. On 18 September, Mr Sheppard transferred from Birmingham to HMP Stoke Heath.
Mr Sheppard continued to be prescribed methadone.
22. On 22 September, a substance misuse worker from Forward Trust saw Mr Sheppard
on the wing and he told them that he did not want their help as he was now receiving
methadone.
23. On 24 September, Mr Sheppard made a formal complaint that he had been taken off
the medication list and had not received his methadone. Staff responded and
reassured him that he was still prescribed methadone and there was no reason why
he would not receive it. Medical records confirm that he was prescribed 40ml of
methadone from 18 September onwards.
24. On 6 November, Mr Sheppard asked to see Forward Trust and a nurse put him on a
waiting list for an appointment.
25. On 8 November, Mr Sheppard referred himself to the mental health team. He said
that he had difficulties with anxiety, depression and trauma from a bereavement. He
was put on a waiting list.
26. On 9 November, a nurse saw Mr Sheppard and noted that he appeared settled and
engaged well. The nurse told him that he was on a waiting list for Forward Trust. Mr
Sheppard said that he wanted extra support alongside his methadone script. The
nurse noted that Mr Sheppard raised no immediate concerns and was content to
remain on the waiting list.
27. On 14 November, a substance misuse worker from Forward Trust assessed Mr
Sheppard and noted that he appeared well. Mr Sheppard told her that he was being
released the following month and still wanted to speak to Forward Trust because he
did not want to use illicit substances in the community. She planned for him to have
six structured intervention sessions focusing on triggers, motivation and relapse
prevention. She posted him in-cell packs (workbooks) to complete on drug
awareness, coping with triggers, motivation and relapse prevention.
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28. On 16 November, Mr Sheppard asked a nurse for medication for anxiety and
depression due to dealing with a bereavement. A GP at Stoke Heath prescribed him
sertraline (an antidepressant). She asked the counselling team to offer some talking
therapy sessions to deal with bereavement. Over the next two weeks, he completed
the ‘living with loss’ course.
29. On 23 November, Mr Sheppard asked a nurse for a healthcare appointment because
he had been feeling light-headed which was making him anxious. On 28 November,
Mr Sheppard saw a nurse, who recorded a high blood pressure reading (157/77).
The nurse arranged for Mr Sheppard to have his blood pressure checked twice a
week and to monitor him for a few weeks before asking a GP if he required
medication. Over the following weeks, healthcare staff checked his blood pressure,
and it remained high.
30. On 7 December, Mr Sheppard attended a treatment review. The nurse noted that Mr
Sheppard had no heart issues or respiratory concerns, and his physical health was
generally okay. Mr Sheppard told the nurse he had been receiving some
bereavement support and he was working with Forward Trust doing in-cell
workbooks. He said that he had no accommodation on release.
31. On 11 December, a nurse saw Mr Sheppard for a review. He requested further
medication for his anxiety, depression and sleep issues. On 14 December, he was
prescribed a medication to help him sleep.
32. On 18 December, a substance misuse worker saw Mr Sheppard on the wing for a
structured intervention session. He told her that he was being released one day early
on 21 December. She noted that he appeared well, and he said that he was ‘good’.
She told him that an appointment would be arranged in the community for him to
collect his methadone prescription. A nurse also wrote that a community referral form
was sent to a community substance misuse service.
33. On 20 December, a nurse noted in the medical records that an appointment had
been arranged with Change, Grow, Live (CGL – a substance misuse service in the
community) for 22 December. Mr Sheppard was given a naloxone kit (used to
reverse the effects of an opioid overdose). A Forward Trust staff member gave Mr
Sheppard naloxone training.
34. On 21 December, a nurse assessed Mr Sheppard was fit for discharge. His blood
pressure was 109/57, which was within normal range. His pulse rate and temperature
were within normal range. His oxygen saturation level was 94%, which was slightly
outside of the normal range. Mr Sheppard also saw a substance misuse worker, who
gave him advice on his reduced tolerance to drugs and told him how to keep safe in
the community. Mr Sheppard again said that he was being released homeless.
Pre-release planning
35. Mr Sheppard was released under the discretionary release scheme (when a prisoner
can be released up to two days early if their release date falls on a Friday or before a
Bank Holiday to support their resettlement). Mr Sheppard’s release date was
changed from 22 December to 21 December.
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36. Prison staff made an appointment for Mr Sheppard with the Department for Work and
Pensions (DWP) to claim benefits on release. On 28 September, Mr Sheppard
attended an appointment with a DWP worker. Mr Sheppard applied for a new bank
card and birth certificate, which were sent to the prison on 24 October.
37. On 25 October, Mr Sheppard was allocated a community offender manager (COM).
38. On 22 November, a Probation Service Officer (PSO) who helps source
accommodation, documented that he had referred Mr Sheppard to 24 housing
providers to source accommodation.
39. On 30 November, following discussion with the COM, the PSO documented that he
had accepted an accommodation offer for Mr Sheppard for a property with Nexus
Housing and confirmed that his release date was 21 December. (Nexus Housing
offers accommodation to homeless and vulnerable people in Birmingham.) There is
no evidence that anyone told Mr Sheppard he had accommodation until he was
released.
40. On 7 December, a DWP worker booked an appointment with the job centre in the
community.
41. On 12 December, a pharmacist noted that Mr Sheppard was prescribed 28 days of
sertraline, to be given to him on 19 December to prepare for his release. This was so
he had enough medication to last him four weeks after his release.
42. On 13 December, Mr Sheppard declined support with registering with a community
GP.
43. On 20 December, a nurse recorded that CGL had responded to their referral. Mr
Sheppard was given an appointment for 22 December to collect his methadone. The
nurse noted that Mr Sheppard had a naloxone kit.
44. On 21 December, a prison manager gave Mr Sheppard a copy of his licence with the
conditions of his release. The manager told him to report to the Birmingham city
centre probation office at 11.30am. Staff gave Mr Sheppard a travel warrant for his
train journey from Stoke Heath to Birmingham and a release grant of £89.52.
Post-release supervision
45. Mr Sheppard attended his appointment with his COM as required on 21 December.
She noted that he appeared distracted. Mr Sheppard denied taking illicit drugs. She
completed the induction paperwork. Mr Sheppard said that he could not remember
the time or date of his CGL appointment. He did not report any health concerns.
46. The COM explained Mr Sheppard’s licence conditions to him, and he signed to say
that he understood them. She gave him the address of his accommodation and
instructed him to him to attend his accommodation that day for his induction.
47. On 27 December, Mr Sheppard missed a scheduled probation appointment. His
COM had returned from leave on that date and thought that Mr Sheppard had moved
into his accommodation. He was sent a compliance letter for the missed
appointment.
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48. On 3 January 2024, Nexus housing provider emailed the COM to say that Mr
Sheppard had not moved into the accommodation. She discussed this update with
her manager, and they decided that Mr Sheppard would be recalled to custody. They
were unaware at that point that Mr Sheppard had died.
Circumstances of Mr Sheppard’s death
49. On 24 December, at approximately 4.40pm, Mr Sheppard went to a temporary
homeless shelter run by Birmingham Christmas Shelter.
50. On the morning of 25 December, Mr Sheppard spoke to shelter staff and asked for
clothing. Mr Sheppard told staff he felt unwell, so they asked him to sit down. He
started to feel worse, so they put him in the recovery position. Mr Sheppard felt better
and sat down on a chair but then collapsed and became unresponsive.
51. Shelter staff requested an ambulance which arrived four minutes later. The shelter
staff performed CPR while they waited for the ambulance to arrive. At 8.50am,
paramedics confirmed that Mr Sheppard had died.
Post-mortem report
52. The post-mortem report concluded that Mr Sheppard died from Influenza A (Human
H3 variant) pneumonia.
53. Influenza A is also known as swine flu. For most people, swine flu is mild. The
symptoms include tiredness, a high temperature, a cough, a sore throat, aching
muscles, chills, a runny nose, loss of appetite and sometimes vomiting and
diarrhoea. Flu symptoms normally develop about one to four days after being
exposed to the virus and usually, the symptoms last for around a week. Some people
can become seriously ill with flu, including those that are immunocompromised.
(Immunocompromised means the body's immune system is weakened).
Findings
Clinical Care
54. The clinical reviewer is satisfied that in the days leading up to, and on the day of Mr
Sheppard’s release, he did not report any concerns about his physical health and
was not observed to be physically unwell by healthcare or prison staff. Mr Sheppard
was seen by a nurse for clinical observations on the day of his release who reported
that he was fit for discharge. The clinical reviewer noted that the results gave the
nurse no cause for concern. Mr Sheppard did not raise any concerns regarding his
health during that contact or subsequently when he attended his probation
appointment on 21 December.
55. The clinical reviewer also found that Mr Sheppard’s blood pressure was appropriately
monitored. Mr Sheppard’s structured interventions care plan with Forward Trust was
reviewed in a timely manner and healthcare provided appropriate medication,
naloxone training and appointments with community services. She noted that Mr
Sheppard’s medication and continuity of care was timely and appropriate.
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56. Overall, the clinical reviewer found that Mr Sheppard’s care at Stoke Heath was of a
good standard and equivalent to that which he would have received in the
community. She made one recommendation, which did not impact on her
assessment of equivalence, that the Head of Healthcare will wish to address.
Substance Misuse Services
57. We are satisfied that the COM put appropriate measures in place to address Mr
Sheppard’s substance misuse issues when he was released from prison. She
identified that Mr Sheppard’s offending was linked to his substance misuse, and she
included drug testing and engagement with community drug and alcohol services as
a condition of his licence.
Accommodation
58. We consider that the COM appropriately prepared for his release and secured
accommodation in a timely manner. We found that considerable efforts were made
by probation to source accommodation with numerous referrals to housing providers.
Despite accommodation being secured for Mr Sheppard three weeks before his
release, he was unaware that he had a place to live until he was told by her on the
day of his release. The Probation Service will want to ensure that such news is
communicated more effectively in the future. Nevertheless, Mr Sheppard did not
attend the accommodation secured for him for unknown reasons. We do not think
that his failure to access his accommodation impacted on his death.
Adrian Usher
Prisons and Probation Ombudsman November 2024
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