Florence Johnson

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Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Ms Florence Johnson
on 27 August 2023, following her
release from HMP Styal
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 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 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. Ms Florence Johnson was found hanging on 24 August 2023, following her release
from HMP Styal on 14 August. She was taken to hospital but died on 27 August.
She was 50 years old. We offer our condolences to Ms Johnson’s family and
friends.
5. Ms Johnson had a history of substance misuse and mental health issues and was
under the care of both the mental health team and the substance misuse team at
Styal. Before being released, her substance misuse care was transferred to a
community service. However, the mental health team at Styal was unable to refer
Ms Johnson to the community mental health team (CMHT) as she did not have a
release address (and the local CMHT does not accept referrals without an address).
The acceptance criteria of the CMHT is outside our remit. We consider that Ms
Johnson’s community offender manager made the appropriate accommodation
referrals for her and managed to secure temporary housing on the day of her
release. We hope that the introduction of the RECONNECT care after custody
service to Styal later this year will help to bridge the gap between prison and
community care and improve continuity of care for those with health needs.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Ms Johnson’s death on 31 August 2023.
8. The PPO investigator obtained copies of relevant extracts from Ms Johnson’s
prison and probation records.
9. We informed HM Coroner for Cheshire of the investigation. We have sent the
Coroner a copy of this report.
10. The Ombudsman’s family liaison officer contacted Ms Johnson’s sister to explain
the investigation and to ask if she had any matters she wanted us to consider. She
had no questions but asked for a copy of our report.
11. We shared our initial report with HMPPS. They pointed out one minor factual
inaccuracy which has been amended in this report.
12. We sent a copy of our initial report to Ms Johnson’s sister. She did not notify us of
any factual inaccuracies.
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Background Information
HMP Styal
13. HMP Styal is a prison and young offender institution (YOI) in Wilmslow, Cheshire,
for women aged 18 and over. Spectrum community health CIC provides healthcare
and substance misuse services. Mental health services are contracted from Greater
Manchester Mental Health NHS Foundation Trust.
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 Styal was in October 2021. Inspectors found
that outcomes for women at Styal were reasonably good across healthy prison
outcomes (safety, respect, purposeful activity, rehabilitation and release planning).
They found that the handover from prison to community offender managers was
timely and well managed, and that the mental health service worked effectively with
community services to ensure continuity of care for those who were released.
HM Inspectorate of Probation
16. The most recent inspection of the effectiveness of probation work in Cheshire and
Greater Manchester was in April 2019. Inspectors found that through the gate
provision for individuals leaving prison was poor. There was sufficient planning and
activity to meet resettlement needs in fewer than half of the cases assessed. Only a
minority of substance misuse and mental health needs were sufficiently
accommodated.
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Key Events
17. On 20 June 2023, Ms Florence Johnson was sentenced to four months
imprisonment for assault of an emergency worker. She was taken to HMP Styal.
Mental health services
18. When she arrived at Styal, Ms Johnson told a nurse that she had been diagnosed
with bipolar disorder and had a history of self-harm. She said she had last self-
harmed a week before but did not have any current thoughts of suicide or self-harm.
Ms Johnson was discharged from community mental health services in April 2023
for refusing mental health support. The nurse referred her to the mental health team
at Styal.
19. On 26 June, Ms Johnson saw a nurse for a mental health review. Ms Johnson told
the nurse that she had been hearing voices and asked for her medication to be
increased. Ms Johnson said that alcohol usually helped her with the voices as they
went away when she drank. The nurse placed her on a waiting list for an
appointment with the psychiatrist to review her medication. There is no evidence
that Ms Johnson was reviewed by the psychiatrist before her release.
20. Ms Johnson remained under the care of the mental health team at Styal and
continued to have reviews with her named mental health nurse as part of her care
plan. She said she had no thoughts of suicide or self-harm while at Styal.
21. On 27 July, Ms Johnson’s community offender manager (COM) referred her to the
probation mental health and dual diagnosis team to support with mental health
services in the community.
22. The mental health team at Styal were unable to refer Ms Johnson to a community
mental health team as she had been homeless before prison. The head of the
mental health team told us that the local community mental health services will not
accept a referral if the individual does not have a registered address (regional
community mental health services have different referral policies).
23. On 14 August, a mental health nurse sent a letter to Ms Johnson’s GP asking for
them to refer Ms Johnson to the community mental health team once she had an
address.
Substance misuse services
24. When she arrived at Styal on 20 June, Ms Johnson told the reception nurse that
she regularly used crack and diazepam (a sedative, which she bought illegally), and
drank alcohol daily. Ms Johnson said that she was prescribed Espranor (an opioid
detox medication) in the community and did not take any other opiate drugs
alongside this. The nurse arranged for Ms Johnson to be prescribed alcohol
detoxification medication and referred her to the Substance Misuse Service (SMS).
25. The next day, the nurse confirmed with the community substance misuse team that
Ms Johnson was prescribed Espranor, and she arranged her prescription. The
healthcare team monitored her daily for signs of withdrawal.
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26. On 11 August, a substance misuse worker saw Ms Johnson for a pre-release
appointment. She gave Ms Johnson advice on harm reduction and told her that her
tolerance to drugs and alcohol would be reduced upon her release. She trained Ms
Johnson how to use naloxone (a medication that reverses the effects of an
overdose of heroin or other opioids) and encouraged her to collect this from
reception on the day of her release. The substance misuse worker confirmed that
Ms Johnson had an appointment with the community substance misuse service,
Change Grow Live, on the day of her release for her Espranor prescription.
Accommodation
27. On 23 June, Ms Johnson told her prison offender manager (POM) that she wanted
support to find some housing. She told her POM that she did not want to move to a
home detention curfew address and was not ready for a recovery home. Her POM
agreed to speak to her COM to make referrals for potential housing options.
28. Ms Johnson’s COM submitted a duty to refer application (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). As part of this referral, Ms
Johnson was allocated an intensive support coordinator.
29. On 6 July, Ms Johnson met with her intensive support coordinator from Cheshire
East Council, who was going to be supporting Ms Johnson with her upcoming
release.
30. On 10 August, Ms Johnson’s COM made an accommodation referral to CAS3
(provides temporary accommodation for up to 84 nights for homeless prison
leavers).
Release from HMP Styal
31. On 14 August, Ms Johnson was released from Styal. Upon her release she had
temporary accommodation through Cheshire East Council. As this was not known
to the mental health team at Styal prior to her release, they were unable to refer her
to the community mental health team.
32. Ms Johnson attended her initial appointment with her COM and was supported by
her intensive support coordinator.
33. The community substance misuse service, Change Grow Live, issued Ms
Johnson’s prescription for Espranor. They said she did not need to attend the
service on the day of her release, and they arranged a doctor’s appointment for her
for 21 August.
34. On 16 August, Ms Johnson’s intensive support coordinator emailed her discharge
summary and prescription details from Styal to Ms Johnson’s GP. She also took Ms
Johnson to shop for essential clothing and arranged a food parcel and food
voucher.
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35. On 21 August, Ms Johnson missed her doctor’s appointment at Change Grow Live.
The doctor agreed to continue with her Espranor prescription and arranged another
appointment for 29 August.
36. On 22 August, Ms Johnson was due to attend court for a first hearing on separate
matters. She failed to attend, and a warrant was issued for her arrest.
37. On 23 August, the intensive support coordinator visited Ms Johnson at her flat and
entered when she could not get a response. She found Ms Johnson in bed and
unwell as she had not taken her Espranor and was experiencing withdrawal
symptoms. The intensive support coordinator took Ms Johnson to the pharmacy to
collect her medication and supported her to go to court. Ms Johnson became upset
in the car on the way to court and said she wanted to kill herself. The intensive
support coordinator suggested that she took Ms Johnson to hospital for immediate
help with her mental health, but she did not want to go.
38. The intensive support coordinator phoned the crisis team with Ms Johnson present,
the crisis team advised that it would be best for Ms Johnson to call back after she
had been to court so that the conversation was not interrupted.
39. At court, Ms Johnson found that the charges against her had changed, and she
was now being charged with a more serious offence.
40. After Ms Johnson attended court, Ms Johnson’s intensive support coordinator
offered to take her home. Ms Johnson declined, she was angry about her charges
and said she wanted to go into the town centre. She took her medication with her.
41. The intensive support coordinator phoned Ms Johnson’s substance misuse worker
to update him on the events of the day. He later saw Ms Johnson walking towards
her flat and noted that she looked okay.
Circumstances of Ms Johnson’s death
42. On 24 August, the intensive support coordinator emailed Ms Johnson’s COM. She
explained that she had seen Ms Johnson the previous day and was concerned as
she had said that she was unwell and wanted to die, however had declined for her
intensive support coordinator to take her to hospital.
43. At around 11.30am, Ms Johnson’s COM phoned Ms Johnson to check on her
wellbeing and remind her of her probation appointment on 25 August. Ms Johnson
stated that her COM had woken her, and the conversation was brief. The COM
agreed to phone her later in the day.
44. At approximately 1.50pm, Ms Johnson phoned her COM. She was distressed and
said she had tried to contact her intensive support coordinator but had not been
able to speak to her. She told her COM that she was unwell and needed help as
she was going to kill herself. Her COM told her she would phone an ambulance, at
which point Ms Johnson became abusive towards her COM and about her intensive
support coordinator. Ms Johnson continued to be abusive on the phone and her
COM told her that she would have to end the call if she did not stop. The COM then
ended the call.
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45. Ms Johnson phoned her COM a few minutes later. She told her that she had bought
some rope and intended to kill herself. Ms Johnson then ended the call.
46. At 1.54pm, Ms Johnson’s COM phoned the emergency services and asked them to
attend Ms Johnson’s flat as she was concerned for her safety. She then phoned the
intensive support coordinator to tell her that she had phoned for an ambulance.
47. At 2.11pm, the police found Ms Johnson in her flat hanging. They phoned the
ambulance service to ask for urgent assistance. The police started CPR and
continued until the ambulance crew arrived at 2.21pm and took over Ms Johnson’s
care.
48. Ms Johnson’s condition deteriorated in hospital and on 27 August she died.
Post-mortem report
49. A post-mortem examination was not carried out as the Coroner will determine the
cause of death at inquest. The Coroner gave the likely cause of death as hanging.
Inquest
50. The inquest, held on 12 June 2024, reached a narrative conclusion that Ms
Johnson had “suspended herself by a ligature from a window rail in her home, but
the question of intent remains unclear”.
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Findings
Mental health handover
51. We found that Ms Johnson was well supported by the mental health services at
Styal and treatment focused on developing strategies that would support her in the
community. Ms Johnson wanted to discuss increasing her medication with a
psychiatrist before her release and was put on a waiting list for an appointment. We
found no evidence that she had seen the psychiatrist before her release.
52. As Ms Johnson did not have housing secured for her release, the mental health
team at Styal were unable to refer her to the local community mental health team
(CMHT). This is because the CMHT in the local region will not accept a referral
when the individual does not have an address.
53. The head of the mental health team at Styal told the investigator that when a
prisoner is released without an address, they write a letter to their GP and ask them
to complete the referral once an address is known.
54. While Ms Johnson was not referred to the CMHT for her release, we are satisfied
that the mental health team at Styal did all they could to try ensuring continuity of
care under challenging circumstances.
55. We understand from the mental health team at Styal that the RECONNECT care
after custody service is due to be introduced to Styal within the next year.
RECONNECT seeks to improve the continuity of care of people leaving prison with
an identified health need. This involves working with them before they leave to
support their transition to community-based services. We hope this will help to
bridge the gap between prison and community services.
Substance misuse
56. Ms Johnson had a history of substance misuse. While she was in prison, she was
seen regularly by the SMS team and warned about the risks and dangers of taking
drugs. She was also trained in the use of naloxone and was encouraged to collect a
supply of this from reception upon her release.
57. We found that the substance misuse service at Styal handed over Ms Johnson’s
care to the community substance misuse provider effectively and ensured that she
had continuity of care upon her release.
58. We are satisfied that both the prison and probation services did all they could to
manage the risks associated with Ms Johnson’s substance misuse.
Accommodation
59. Homelessness on release from prison is a significant and complex challenge. While
prison and probation staff can submit referrals to local authorities and charities,
there are occasions when beds are not available, or the individual does not meet
the eligibility criteria for housing. This means that these individuals are released
homeless and are expected to report to the local authority on the day of their
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release in the hope of receiving emergency housing. If an individual is homeless, it
can increase the likelihood that they will commit further crimes or seek shelter and
support in harmful places.
60. Ms Johnson secured temporary accommodation on the day of her release. We
consider that Ms Johnson’s COM appropriately prepared for her release by
promptly completing accommodation referrals to the local authorities and
homelessness charities.
61. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman June 2024
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