Dylan Davies

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Dylan Davies,
on 28 December 2021,
following his release from
HMP Cardiff
A report by the Prisons and Probation Ombudsman
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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 been investigating post-release deaths that
occur within 14 days of a prisoner’s release.
3. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
4. Mr Dylan Davies died of combined drug toxicity and features consistent with
drowning on 28 December 2021, following his release from HMP Cardiff on 17
December. He was 28 years old. I offer my condolences to his friends and family.
5. When Mr Davies met with the prison resettlement team to discuss his re-release; he
said he had no support needs. This contradicted what was recorded in his probation
assessments, which noted his lack of accommodation and substance misuse
issues, and the associated risks. We are concerned that the resettlement team did
not use other available information and relied on what Mr Davies told them when
concluding that no referrals were required. Fortunately, Mr Davies was already
known to services and was given relevant appointments as a result. Had this not
been the case, no support would have been in place and the risks would have
increased significantly.
6. Mr Davies was released from prison on a Friday. At his first probation supervision
appointment he reported that he could not stay at his planned release address. He
then missed a meeting arranged with the local housing provider, a substance
misuse appointment and, several days later, his second probation supervision
appointment. His failure to attend these meetings meant he had breached his
licence conditions. The risks were increased by the fact that community services
are not accessible at weekends. We are concerned, therefore, that there is no
evidence of any contingency planning for Mr Davies, or follow up action regarding
breaches, by the Probation Service.
Recommendations
• The Local Delivery Unit manager of Swansea Neath Port Talbot Probation
Service should ensure that offender managers clearly record decisions
relating to risk and licence conditions in NDelius.
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The Investigation Process
7. The PPO investigator obtained copies of relevant extracts from HMP Cardiff and
probation records.
8. We informed HM Coroner for Swansea of the investigation. He gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
9. The Ombudsman’s family liaison officer contacted Mr Davies’ mother, to explain the
investigation and to ask if she had any matters for the investigation to consider. We
did not receive a response.
10. We shared the initial report with HM Prison and Probation Service. They highlighted
some factual inaccuracies, which we have amended accordingly.
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Background Information
HMP Cardiff
11. HMP Cardiff is a medium secure local prison. It holds approximately 800 male
prisoners who have either been convicted or are on remand. Substance misuse
services are provided by the Cardiff and Vale University Health Board and
psychosocial support by the Welsh Centre for Action on Dependency and Addiction
(WCADA), as part of the Dyfodol consortium, which also delivers drug and alcohol
services in the local community.
HM Inspectorate of Prisons
12. The most recent inspection of HMP Cardiff was in November 2019. Inspectors
reported that the prison was reasonably good at supporting prisoners with
rehabilitation and release plans. They found that the prison exchanged some
information with community offender managers prior to a prisoner’s’ release.
However, there was not enough evidence that community offender managers
undertook a high standard of release planning to ensure that the risk of serious
harm on release would be managed effectively.
The Probation Service
13. The Probation Service supervises individuals serving community orders, provides
offenders with resettlement services while they are in prison (in preparation for their
release) and supervises all individuals for a minimum of 12 months when they are
released from prison on licence. Supervision in the community is carried out by a
community offender manager.
HM Inspectorate of Probation
14. The most recent inspection of Swansea Neath Port Talbot Probation Service was in
January 2022. Inspectors highlighted that casework relating to high-risk individuals
on post-release licences was satisfactory. However, those on licence assessed as
medium risk were not managed as well.
Offender Management in Custody (OMiC)
15. The OMiC model is a case management system for offenders. The model aims to
ensure better co-ordination and sequencing for individuals as they transition from
prison into the community. Individuals have both community and prison offender
managers who contribute to release planning. They also have a key worker - a
dedicated prison officer that they meet with regularly, for the purpose of developing
a constructive and motivational relationship that helps with choices they need to
make during their time in custody. The level of support provided by these roles is
determined by the length of sentence and level of risk highlighted in probation
assessments.
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Integrated Offender Management (IOM)
16. The IOM system is designed to reduce the risk of reoffending presented by prolific
offenders, through multi-agency collaboration. It involves an increased level of
monitoring and risk reduction support in the community, for those identified locally
as a priority. Agencies meet regularly to share information and ensure joined up
decision making processes.
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Key Events
Background
17. On 11 February 2019, Mr Dylan Davies was convicted of burglary and was given a
36-month prison sentence. It was not his first time in prison.
18. Mr Davies was released on 29 April 2021. He was recalled to HMP Cardiff on 23
November for not complying with his licence conditions. He was returned on a fixed
term recall for a set period of 28 days.
19. Mr Davies had a history of depression and a diagnosed personality disorder. He
had been admitted to hospital for a psychotic episode in 2017. He was prescribed
antidepressants and antipsychotic medication, which he took as directed while in
prison and in the community following release. He also had a history of using both
non-prescribed medication and illicit drugs in the community.
20. Mr Davies had a long history of offending and was identified as a prolific offender.
He was allocated to the Integrated Offender management (IOM) Team at Swansea
Neath Port Talbot Probation to manage the associated risks.
21. On 21 November Mr Davies’ community offender manager (COM) updated Mr
Davies’ probation assessment of risk and need (OASys assessment). The
assessment outlined risk factors associated with him living at his mother’s address
on release and suggested that the long-term plan was for him to seek independent
housing with his local authority. It also noted Mr Davies’ history of substance
misuse and recreational drug use.
22. When Mr Davies arrived at Cardiff on 23 November, a nurse undertook an initial
healthcare screening. Mr Davies told her that he had used drugs in the past and
she referred him for an assessment with the prison drug team. She also arranged
for his prescription antidepressant and antipsychotic medication to continue.
Dyfodol staff assessed Mr Davies the following day.
Pre-release planning
23. The same day, the COM made a housing referral to the Forward Trust, a
Commissioned Rehabilitative Service providing accommodation support and
interventions both pre and post-release.
24. On 30 November, the COM was notified that someone had been identified as Mr
Davies’ prison offender manager (POM) contact. (Mr Davies was not allocated a
prison offender manager because he was only in prison for 28 days and was
medium risk.) She was able to help him with any questions he had before his
release, and she would act as the liaison with the COM.
25. There is no record in the prison or probation case management systems that any
further contact was made between the POM and the COM prior to Mr Davies’
release.
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26. On 30 November Mr Davies was seen by a prison resettlement officer in
preparation for his release on 17 December. She reviewed his plans for release and
noted that Mr Davies had settled in well at Cardiff and did not have any concerns
that required her support. Mr Davies said that he had lived with his mother before
prison and could return there on release. He also spoke about his mental health
diagnosis and medication. Mr Davies said that he had no substance misuse issues
and had not been seen by Dyfodol in prison.
27. While Mr Davies’ substance misuse issues were not captured by the resettlement
team, they were picked up by Dyfodol due to Mr Davies’ previous use of the service
and his comments in Reception.
28. On 14 December Mr Davies was reviewed by a keyworker from the prison
substance misuse team, Neath Dyfodol. (Neath Dyfodol is also the community drug
team.) He was given information on the risks of using substances at the same time
as his prescribed medication, and strategies for harm minimisation when in the
community. The keyworker referred Mr Davies for an appointment with the
community Neath Dyfodol on the day of his release.
29. On Friday 17 December, the day of Mr Davies’ release, an officer issued Mr Davies
with a copy of his licence conditions. Mr Davies had standard licence conditions that
required him to attend probation appointments and stay at his mother’s address
unless otherwise authorised by Probation. The COM had noted that the risk of him
relapsing if homeless during the COVID pandemic outweighed the risks associated
with him returning to live with his mother. He was also required to address his use
of controlled drugs and alcohol and offending behaviour problems with support from
the Swansea Probation Office and/or Neath Dyfodol Office (community drug team).
The licence conditions included a requirement to comply with regular drug testing.
30. Later that day Mr Davies was released with a travel warrant to attend his first
probation appointment in Swansea at 1.00pm. He was also asked to attend an
appointment with Neath Dyfodol Office in the afternoon.
Post-release
31. The COM was not in the office on the day of Mr Davies’ first supervision
appointment. A duty Probation Service Officer carried out the appointment on her
behalf. Mr Davies told him that he could not stay at his mother’s address. He
confirmed that he would engage in his scheduled telephone appointment with Neath
Port Talbot Housing Options later that afternoon. The duty Probation Service Officer
gave Mr Davies a travel warrant to get to his substance misuse appointment with
Neath Dyfodol in Port Talbot. There is no record of steps taken to resolve the lack
of housing that night or over the following days before longer term accommodation
was secured.
32. Mr Davies did not attend his planned appointment with Neath Dyfodol later that day.
Records from the community drug team indicate that a member of staff notified
probation.
33. There is no evidence that Mr Davies attended the telephone appointment with
Neath Port Talbot Housing Options that afternoon as planned and no evidence of
any follow up action regarding this.
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34. During the evening of 17 December, a member of the public found Mr Davies
unconscious. He was admitted to Morriston Hospital’s accident and emergency
department at approximately 9.00pm on the basis of a suspected drug overdose.
He remained in hospital overnight. At 8.30am the following morning, he was seen
by a mental health nurse for a mental health assessment. He told her that he had
been celebrating with non-prescription drugs, following his release from custody. He
was assessed as posing a low risk of harm of suicide via substance use or
overdose and discharged. The hospital ordered a taxi and support from the Red
Cross to take Mr Davies to his mother’s house.
35. At 10.40pm on 20 December, as a follow up to a referral from the hospital, the
police conducted a welfare check on Mr Davies. He was not present at his address.
The next day, the police notified the COM, via email, but she was not in the office.
There are no further probation records regarding Mr Davies between 21 December
and 24 December when he was due for his next probation appointment.
36. Mr Davies did not attend his second probation appointment on 24 December. There
is no record of the action taken by probation staff in response to this.
37. On the evening of 24 December, Mr Davies was reported missing to the police by
his mother. He had failed to return home having been out with friends the previous
day. Mr Davies’ friend contacted Mr Davies’ mother to ask if he had made it home,
as he had been under the influence of drugs. The friend said Mr Davies had fallen
down a hill into water.
38. On 28 December, a PC at South Wales Police informed the COM that a body,
believed to be that of Mr Davies, had been recovered in a waterway in Port Talbot.
On 29 December, the PC confirmed with Probation that the body had been formally
identified as Mr Davies.
Post-mortem report
39. The Coroner concluded that Mr Davies died of combined drug toxicity (damage to
organs from a high level of drugs in the body) and features consistent with
drowning. At the Inquest, on 30 June 2022, the Coroner concluded that Mr Davies’
death was due to misadventure.
Support for staff
40. An internal paper review of Mr Davies death was initiated on 31 December 2021 in
line with Probation Instruction 2014-01 (PI 2014-01 - Reviewing and Reporting
Deaths of Offenders Under Probation Supervision in the Community). Support was
offered to the COM by email and included a list of support networks for her to
access.
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Findings
Release planning
41. When the resettlement team met with Mr Davies on 30 November, he said he
required no particular support. The resettlement team recorded that no further
action was required and referred him to probation staff for any further support.
They did not consult any other information sources, such as offender managers or
case management systems, before arriving at their conclusion. Mr Davies was
referred on to substance misuse and housing support providers because he was
already known to them. For individuals not known to services, this would not have
been the case and would have significantly increased the risks.
Licence conditions
42. Mr Davies was released on a Friday and disclosed that he could not stay at his
approved address as planned. He was required to seek authorisation for any
alternative addresses but there is no record of any discussions about this. Mr
Davies confirmed that he would engage with his scheduled telephone appointment
with housing providers later that afternoon, but there is no record of a contingency
plan in place if he did not attend the meeting. Community services are generally not
accessible over the weekend, which may have caused him to be made homeless.
43. Mr Davies’ prison and probation records document that his regular use of non-
prescribed drugs and alcohol increased his risk of self-harm and suicide (through
accidental or intentional overdose). His licence included a condition to address his
drug use by attending appointments with Neath Dyfodol (community drug team) to
reduce the risk of relapse. He was given an appointment with them on the day of his
release and failed to attend. The Neath Dyfodol office recorded that they were
unable to contact him despite several attempts between Friday 17 and Monday 20
December.
44. There is no record of any action taken by probation as a result of the breaches that
took place following Mr Davies’ release. It is unclear why breach action was not
considered. IOM teams are required to meet every day with the police and
substance use services to discuss updates, decisions and actions regarding all
supervised individuals. This joint work is not recorded on individual case records,
and we make the following recommendation:
The Local Delivery Unit manager of Swansea Neath Port Talbot should ensure
that offender managers clearly record decisions relating to risk and licence
conditions in NDelius.
Friday release
45. Friday release was noted by Mr Davies’ prison offender manager as a factor that
would increase the risk of relapse. We note that in June 2022, the Ministry of
Justice Prisons Strategy White Paper announced plans to end Friday releases for
those vulnerable to addiction, mental health issues and homelessness, in
recognition of the challenges this creates for accessing support services at
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weekends. We are pleased that the Ministry of Justice is taking action to address
these issues.
Inquest
46. The inquest into Mr Davies’ death concluded on 30 June 2022, and returned a
verdict of misadventure.
Kimberley Bingham
Acting Prisons and Probation Ombudsman January 2025
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