Ged Corbett

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Ged Corbett on
19 August 2023, following his
release from HMP Thameside
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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. Mr Ged Corbett died of a heroin overdose on 19 August 2023 following his release
from HMP Thameside on 16 August. He was 28 years old. We offer our
condolences to those who knew him.
5. Mr Corbett had a history of substance misuse. We found that Mr Corbett received
appropriate support for his substance misuse issues while he was at Thameside.
The prison substance misuse service (SMS) saw him regularly and warned him of
the risks associated with drug taking. He remained under their care until he was
released, when he was transferred to a community SMS team. He was released
from prison with a naloxone (medication that can reverse the effects of an opioid
overdose) kit.
6. We consider that Mr Corbett’s community offender manager (COM) appropriately
prepared for his release. She liaised with external support agencies, completed the
relevant housing referrals, and gave him licence conditions to ensure he addressed
his issues relating to substance misuse.
7. Mr Corbett was released homeless. However, we found that his COM had
completed the appropriate accommodation referrals to local authorities and housing
agencies. The provision of suitable accommodation for people leaving prison is an
issue that extends beyond the remit of Thameside or local probation services, and
the local authority may want to be aware of the issues raised in this case.
8. We make no recommendations.
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The Investigation Process
9. HMPPS notified us of Mr Corbett’s death on 6 November 2023.
10. The PPO investigator obtained copies of relevant extracts from Mr Corbett’s prison
and probation records.
11. We informed HM Coroner for Inner North London 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 family liaison officer contacted Mr Corbett’s next of kin, his
father, to explain the investigation and to ask if he had any matters he wanted us to
consider. He asked why Mr Corbett was in prison, how long he was there, and
which prisons he was in. This has been addressed in the report.
13. Mr Corbett’s 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 did not find any factual inaccuracies.
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Background Information
HMP Thameside
15. HMP Thameside is a category B local prison in London which holds up to 1,232
men who have either been convicted or are on remand. It is managed by Serco.
Until 5 May 2023, Oxleas NHS Trust provided healthcare and substance misuse
services at the prison. From 6 May, Practice Plus Group began providing healthcare
services, but substance misuse services are still provided by Oxleas NHS Trust.
HM Inspectorate of Prisons
16. The most recent inspection of HMP Thameside was in November 2021. Inspectors
reported that there was an up-to-date drug strategy and meetings were well
attended, with good oversight of local issues. The substance misuse service
supported prisoners through telephone consultations, one-to-one work,
programmes, and in-cell packs, which prisoners told inspectors were good, and
were meticulously reviewed to ensure completion. Community drug teams were
notified when any of their clients arrived at the prison and were invited in, in
advance of the prisoner’s discharge, to start release planning. Strong relationships
had been developed with many of the London boroughs because of the high
turnover of the prison population. Naloxone (a medication that can rapidly reverse
the effects of an opioid overdose) training and supply had been embedded
successfully over recent months.
17. Inspectors reported that the demand for help with resettlement services was high
and only around a quarter of prisoners said that they were getting the support they
needed before release. Just over half of prisoners leaving Thameside had
accommodation for their first night of release and around three-quarters of the
prisoners had left the establishment with a housing appointment arranged in the
community. To address these serious deficits, leaders had recently engaged with
housing teams in the London boroughs of Croydon and Lambeth, to facilitate
housing assessments for prisoners before release. As a result, a small number of
prisoners had gained access to temporary accommodation on release.
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, 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 supervises people
throughout their licence period and post-sentence supervision.
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Key Events
19. On 9 August 2022, Mr Ged Corbett was sentenced to a community order for sexual
offences, and he was placed on the sexual offenders’ register.
20. On 13 February 2023, Mr Corbett was convicted of assault and sentenced to 34
weeks in prison. He was sent to HMP Hull.
21. On 19 April, Mr Corbett was released from HMP Hull.
22. On 26 April, Mr Corbett was sentenced to 26 weeks in prison for failing to comply
with the requirements of the sexual offences order. He was sent to HMP
Thameside.
Substance misuse services
23. When Mr Corbett arrived at Thameside, he was already on a methadone
detoxification programme (medication used to treat the symptoms of heroin
withdrawal). He continued the programme at Thameside and was taken under the
care of the prison’s substance misuse service (SMS).
24. On 7 May, a nurse at Thameside saw Mr Corbett for a substance misuse
assessment and they agreed on a care plan to address his substance misuse
issues. The nurse warned him about the risks associated with taking psychoactive
substances (PS) in prison, which included heart attack and overdose. She gave Mr
Corbett harm minimisation advice and warned him about the dangers of polydrug
use and misusing prescribed medication. She warned him about the risk of catching
blood borne viruses by sharing needles and gave him advice on the risks related to
drug use and overdosing, especially after a period of abstinence.
25. On 22 May, a nurse at Thameside saw Mr Corbett to discuss his detoxification
programme. Mr Corbett said that he wanted to reduce his methadone to zero before
he was released from prison. The nurse advised against this and warned him about
the dangers of overdose on release. Mr Corbett insisted he wanted to finish his
detoxification before he was released, so a plan was made for him to reduce by 5ml
each week until his release.
26. On 26 June, Mr Corbett completed a naloxone training programme, so that he could
safely administer naloxone in the event of a drugs overdose. (Naloxone is a
medication that can rapidly reverse the effects of an opioid overdose.) Mr Corbett
said that he would like to be released with a supply of naloxone.
27. On 21 July, an SMS worker saw Mr Corbett for a pre-release appointment. They
again warned him about the risks associated with taking drugs on release. As Mr
Corbett did not yet have a community drugs worker, the SMS worker sent his
discharge paperwork to Change Grow Live, a community substance misuse service
in York (in line with his release plans).
28. On 24 July, Mr Corbett said that he did not want to complete his methadone
detoxification programme, so a GP at Thameside discontinued his prescription.
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29. On the day of his release from prison, a nurse gave Mr Corbett a supply of
naloxone, along with training information on how to administer it in the event of an
overdose.
Accommodation
30. On 30 May, Mr Corbett attended a pre-release video call with his community
offender manager (COM). Mr Corbett told his COM that he would like to be released
to Woolwich where he had family support and job opportunities. The COM told Mr
Corbett that she would explore this and let Mr Corbett know if it was possible. Over
the next few months, the COM spoke to agencies working with Mr Corbett, including
the police, and found that there were outstanding allegations of domestic abuse
perpetrated by Mr Corbett in that area. The COM assessed that it was therefore not
suitable for Mr Corbett to return to Woolwich.
31. On 12 July, the COM had a meeting with her manager, a senior probation officer
(SPO). They agreed that Mr Corbett’s risk level should be increased to high, and
that he would benefit from a period in an Approved Premises (AP) on his release
from prison. (APs are used by probation services to monitor and manage the risk
posed by the individual, as well as giving the individual additional support to re-
integrate back into the community.) After the meeting, the COM submitted a referral
to an AP in York. (Mr Corbett had lived in York previously and had been managed
by York Probation Service.)
32. On 1 August, the AP in York contacted the COM and told her that they could not
accept Mr Corbett as they did not have any space for him on the dates required.
33. On 14 August, the 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) to York Council. She also
completed a CAS3 referral (the community accommodation service provides
temporary accommodation for up to 84 nights for homeless prison leavers).
34. Later that day, the CAS3 team contacted the COM and told her that they could not
accept the application as they required a minimum of seven days’ notice to house
an individual with sexual offence convictions.
35. On the day of his release, Mr Corbett was allocated a housing officer from York
Council. The COM emailed the housing officer and asked if she could find Mr
Corbett temporary accommodation for that day. The housing officer said that Mr
Corbett would need to present himself to the council as homeless that day. As Mr
Corbett did not attend his initial appointment, the COM was unable to notify him of
this.
Release from Thameside
36. On 16 August, Mr Corbett was released from Thameside. He was told to report to
York probation office by 2.00pm, but given the distance from Thameside, was given
some leeway. He did not arrive on 16 August. As Mr Corbett did not have a mobile
phone, his COM was unable to contact him. The COM gave Mr Corbett 24 hours in
which to make contact. As he did not make contact and due to the risk of harm he
posed to others, the COM initiated a recall to prison the next day.
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Circumstances of Mr Corbett’s death
37. On the morning of 19 August, a member of the public found Mr Corbett outside an
address in London. Police and paramedics arrived and pronounced Mr Corbett
dead at 11.24am.
38. On 3 October, the Metropolitan Police informed HMPPS that Mr Corbett had died.
Post-mortem report
39. The post-mortem report concluded that Mr Corbett died of acute respiratory
depression and coma due to heroin toxicity.
40. The inquest, held on 15 January 2024, concluded that Mr Corbett’s death was drug
related.
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Findings
Substance misuse services
41. Mr Corbett had a history of substance misuse. While he was in prison, he was seen
regularly by the SMS team who advised him not to come off his methadone script
and warned about the risks and dangers of taking drugs. He was also trained in the
use of naloxone and was released with a supply of this. As Mr Corbett did not
attend his initial appointment, the COM was unable to discuss his licence conditions
with him. We are satisfied however that Mr Corbett’s COM put appropriate
measures in place to address his substance misuse issues when he was released
from prison. This included adding licence conditions to comply with any
requirements relating to addressing his substance misuse issues. We are satisfied
that both the prison and probation services did all they could to manage the risks
associated with his substance misuse.
Accommodation
42. 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
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.
43. We consider that Mr Corbett’s COM suitably prepared for his release by completing
accommodation referrals to an approved premises, the local authorities and
housing agencies. The provision of suitable accommodation for people leaving
prison is an issue that extends beyond the remit of the prison and local probation
services, and the local authority may want to be aware of the issues raised in this
case.
Adrian Usher
Prisons and Probation Ombudsman April 2024
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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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