Dominic Davies

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Independent investigation into
the death of Mr Dominic Davies
on 9 March 2024, following his
release from HMP Bullingdon
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 Dominic Davies died from multiple injuries after being struck by a train on 9
March 2024, five days after his release from HMP Bullingdon. He was 37 years old.
We offer our condolences to those who knew him.
5. Toxicology tests showed that Mr Davies had consumed alcohol and cocaine before
his death. We found that Mr Davies received good support with his substance
misuse issues at Bullingdon. Substance misuse support was also put in place for
when he was released from prison.
6. Mr Davies was released homeless. Although he was being assisted to find housing
by Slough Borough Council, this had not been secured prior to his release. The
provision of suitable accommodation is a matter for the local authority and is outside
the remit of Bullingdon and local probation services.
7. Although Mr Davies had a community offender manager based in Haringey, he did
not have a designated community offender manager in the area he was being
released to, meaning no pre-release planning had been completed to support his
transition into the community. However, we acknowledge that this was due to the
short length of his sentence, and complicated by probation regional allocation
procedures. We found that these factors did not contribute to Mr Davies’ accidental
death.
8. We make no recommendations.
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The Investigation Process
9. HMPPS notified us of Mr Davies’ death on 11 September 2024.
10. The PPO investigator obtained copies of relevant extracts from Mr Davies’ prison
and probation records.
11. We informed HM Coroner for Berkshire of the investigation. They gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
12. The Ombudsman’s office contacted Mr Davies’ next of kin, his mother, to explain
the investigation and to ask if she had any matters she wanted us to consider. She
was concerned that Mr Davies was released three days early on the End of
Custody Supervised Licence (ECSL) scheme. She asked if this had any impact on
the support Mr Davies was given regarding accommodation and finances. This has
been addressed within the report.
13. Mr Davies’ next of kin received a copy of the initial report. They did not make any
comments.
14. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
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Background Information
HMP Bullingdon
15. HMP Bullingdon is a local and resettlement prison, serving the courts of
Oxfordshire, Berkshire, Buckinghamshire and Wiltshire. It holds category B male
prisoners who have been convicted, as well as those on remand. Inclusion, from
Midland Partnership NHS Foundation Trust, provide drug and alcohol psychosocial
interventions, and Practice Plus Group provide clinical services.
Probation Service
16. 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.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Bullingdon was in November 2022. Inspectors
reported that, as with many prisons across England and Wales, Bullingdon had a
chronic shortage of staff, many of whom were inexperienced. Most prisoners did not
spend long at Bullingdon. At the time of the inspection, over three-quarters had
been there for less than six months and about 170 prisoners were released into the
community each month. In many cases, prisoners’ needs, especially for housing,
were not addressed until just before release, and prisoners’ anxieties were
exacerbated due to a lack of contact to keep them informed of what was being
done.
18. Inspectors reported that overall, substance misuse services at Bullingdon were
good. Pre-release planning was thorough, focusing on relapse prevention, harm
minimisation and continuing treatment if required. Naloxone (to reverse the effects
of opiate overdose) was offered on release where appropriate.
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Key Events
Background
19. On 18 January 2024, Mr Dominic Davies was released from HMP Bullingdon where
he had been serving a two-week sentence for breaching a supervision order. On 1
February, Mr Davies was arrested and charged with assaulting an emergency
worker. The next day, he was sentenced to 14 weeks in prison and sent back to
Bullingdon.
20. Despite having lived in Slough, Berkshire, prior to his arrest, Mr Davies was
automatically allocated to the Haringey Probation Delivery Unit (PDU) in North
London, as they were already managing him for a previous offence.
21. At the time of his arrest, Mr Davies was homeless, however a duty to refer (DTR -
where certain public authorities must notify local authorities that a person who has
engaged with them might be homeless or at risk of homelessness) had already
been completed to Slough Borough Council, and Mr Davies had an allocated
housing officer.
Pre-release planning
22. When Mr Davies arrived at Bullingdon, he was already on a methadone
detoxification programme (medication used to treat the symptoms of heroin
withdrawal). He continued the programme at Bullingdon and was added to the
substance misuse services caseload.
23. On 6 February, Mr Davies attended an initial substance misuse assessment with an
inclusion recovery worker. Mr Davies said that after his previous release in January,
he relapsed into daily alcohol, heroin and crack cocaine use. As Mr Davies had only
a few weeks to serve in prison, the recovery worker created a care plan that
focused on harm minimisation and relapse prevention. He gave Mr Davies advice to
minimise the risk of overdose which included not using drugs by himself, only using
small amounts to test their strength, and to smoke heroin rather than inject it (as
injecting increased the risks of overdose). He also warned Mr Davies about the
dangers of mixing drugs with alcohol and how this could further increase the risks of
overdose. He gave Mr Davies 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. When asked, Mr Davies said that he was
already trained in the use of naloxone (a medication used to reverse the effects of
opioid overdose) and agreed to be given a naloxone kit on his release. The
recovery worker gave Mr Davies a copy of his care plan and after the appointment,
referred Mr Davies to Turning Point, the community substance misuse service
based in Slough, in preparation for his upcoming release.
24. On 5 February, a Senior Probation Officer (SPO) based in Slough, rejected a
regional transfer application from Haringey Probation. The SPO told Haringey
Probation that, as Mr Davies had been convicted of another offence, his risk
assessments would need to be updated and release planning arrangements would
need to be initiated before Slough could accept the transfer.
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25. On 25 February, prison officers found Mr Davies under the influence of an illicit
substance. The next day, he told an Inclusion recovery worker that he had used
psychoactive substances (PS) out of boredom. The recovery worker warned Mr
Davies about the dangers associated with PS use, including the long-term
implications it could have on his health. She also reminded Mr Davies of harm
reduction techniques as well as safer methods of using drugs.
26. On 1 March, the allocated probation officer based in Haringey, emailed the SPO in
Slough stating that Mr Davies was due to be released homeless to Slough on 4
March and asked them to provide temporary care-taking instructions to enable the
licence to be created. This was actioned. Later that day, a probation officer in
Slough spoke with Slough Borough Council and informed them of Mr Davies’
imminent release. Slough Borough Council said that Mr Davies would need to
report to their office on the day of his release for a homelessness assessment with
a senior housing officer.
Release from Bullingdon
27. On 4 March, a nurse saw Mr Davies prior to his release from prison. The nurse
gave him a naloxone kit with instructions on how to use it, and a seven-day
methadone script. Mr Davies was released with a discharge grant of £89.52, a
travel grant of £4, and a copy of his licence. He was also given instructions to report
to the duty probation officer at Slough Probation Office for 2.00pm that day.
28. Mr Davies did not attend his initial appointment as instructed. The duty officer did
not have an up-to-date contact telephone number for Mr Davies and was aware that
he was homeless. She informed a senior probation officer of this information, and
the probation officer in Haringey.
29. On 6 March, Mr Davies had still not attended or contacted Slough Probation. As he
was homeless, his whereabouts were unknown and he had a history of non-
compliance, the SPO in Haringey assessed that his risk could not be managed in
the community, so she initiated recall procedures.
Circumstances of Mr Davies’ death
30. At approximately 9.00am on 9 March, Mr Davies climbed down onto the railway
tracks at Reading West Railway Station, to get onto the opposite platform. As he
attempted to climb onto the platform, he was struck by an incoming train.
Paramedics and the local fire service arrived on scene shortly afterwards and Mr
Davies was taken by air ambulance to a local hospital. Despite their efforts to save
his life, shortly after arriving at hospital, Mr Davies died.
Post-mortem report
31. The post-mortem report concluded that Mr Davies died from multiple injuries with
left haemothorax and intra-abdominal haemorrhage (internal bleeding caused by
trauma to the chest and abdomen).
32. The pathologist detected ethanol (alcohol) and cocaine in Mr Davies' blood,
indicating recent recreational use. Additionally, therapeutic levels of morphine,
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methadone, and diazepam were present, which, when combined, would have
enhanced their sedative effects, and impaired cognition.
33. At the inquest, held on 20 September 2024, the Coroner concluded that Mr Davies
died by misadventure.
Findings
Pre-release planning
34. Mr Davies was released three days early under the End of Custody Supervised
Licence (ECSL) scheme. The scheme allowed eligible prisoners to be released up
to 18 days early from their scheduled release date and was primarily used to
manage prison overcrowding. The responsibility of planning for Mr Davies’ release
was held by his community offender manager (COM) based in Haringey. Although
temporary post-release arrangements were appropriately made for Mr Davies to be
managed by a probation officer in Slough, no pre-release work had been
completed, and he was released with a set of only standard licence conditions. It
would have been good practice for Mr Davies' licence conditions to reflect his
rehabilitation needs, such as conditions to address his substance misuse. However,
given that his licence period lasted only for three days after his release, we
recognise that this was unlikely to have had any significant impact on him.
35. Mr Davies was released homeless. We recognise that Slough Borough Council was
already assisting him in securing accommodation, and it is unlikely that involvement
from a COM would have significantly expedited or influenced this process.
However, had a COM been assigned to Mr Davies in Slough (rather than Haringey)
prior to his release, they might have been able to provide guidance and support in
securing local alternative temporary housing arrangements, such as through CAS3
(a pathway for tackling homelessness for prison leavers), Commissioned
Rehabilitative Services (CRS) accommodation providers, or local homelessness
charities. We do however recognise that was not possible due to regional probation
allocation procedures and the short length of Mr Davies’ sentence.
36. Overall, Mr Davies’ short custodial sentence gave limited time for prison and
probation services to work with him to develop any comprehensive release plans.
Unfortunately, this is a common theme for individuals serving short sentences, and
we consider that his early release under the ECSL scheme had no significant
impact on this process. We acknowledge that the late allocation of a COM and the
absence of detailed release plans were not factors in his accidental death and,
sadly, were unlikely to have altered the outcome for him. For this reason, we make
no recommendation.
Substance Misuse Support
37. Mr Davies had a history of substance misuse. Although he was in prison for only
four weeks, during this time, he was appropriately supported by the prison’s SMS
team, Inclusion, and warned about the risks and dangers associated with substance
misuse. The prison promptly and appropriately referred Mr Davies to Turning Point
to ensure the continuity of his methadone detoxification programme, and so that he
had access to substance misuse support upon release. He was also trained in the
use of naloxone and released with a supply of this.
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38. We are satisfied that, given the limited time they had to work him, the prison did all
they reasonably could to manage the risks associated with his substance misuse.
Adrian Usher
Prisons and Probation Ombudsman May 2025
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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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