George Day

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Independent investigation into
the death of Mr George Day
on 15 December 2022, following
his release from HMP Ranby
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
Events
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. 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.
3. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
4. Mr George Day died from the toxic effects of heroin, pregabalin (an opioid painkiller)
and cocaine on 15 December 2022, following his release from HMP Ranby on 8
December. He was 40 years old. I offer my condolences to those who knew him.
5. We found that Mr Day received good support with his substance misuse issues in
prison. Before his release, he was warned about the risks of overdose and given
naloxone (medication that can rapidly reverse an opioid overdose).
6. We found no issues of concern and make no recommendations.
Prisons and Probation Ombudsman 1
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The Investigation Process
7. The PPO investigator obtained copies of relevant extracts from Mr Day’s prison and
probation records.
8. We informed HM Coroner for Derby of the investigation. They 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 Day’s next of kin to explain
the investigation and to ask if he had any matters he wanted us to consider. He did
not respond to our letter.
10. 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 Ranby
11. HMP Ranby is a Category C adult male training and resettlement prison which
holds up to 1,035 male prisoners who have been convicted. Nottinghamshire
Healthcare NHS Foundation Trust provides physical health, mental health and
substance misuse services.
HM Inspectorate of Prisons
12. The most recent inspection of HMP Ranby was in 2022. Inspectors reported that
prescribing for opiate addiction was not in line with expected practice, as the
prescriber did not attend the prison or consult prisoners directly. Methadone was
the only opiate substitution therapy (OST) available, limiting patients’ choices. They
found that one-to-one substance misuse interventions were limited because of
substantial staff vacancies, but overall, patients were complimentary of the care
given to them. Naloxone (an opiate reversal agent) was issued on release, following
training sessions on its use. Discharge plans were in place for those being
released, in partnership with the Reconnect team.
Probation Service
13. 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. They
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.
Prisons and Probation Ombudsman 3
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Key Events
14. On 25 July 2022, Mr George Day was convicted of shoplifting and was sentenced to
nine months in prison. He was sent to HMP Nottingham.
15. Mr Day was a heroin user. When he arrived at Nottingham, staff placed him on a
methadone (medication used to treat heroin dependency) detoxification
programme.
HMP Ranby
16. On 4 August, Mr Day was moved to HMP Ranby. He continued his methadone
detoxification programme at Ranby.
17. A substance misuse worker met Mr Day and discussed the overdose risks linked to
the use of multiple drugs and warned him about drug tolerance levels after a period
of abstinence. The substance misuse worker gave Mr Day advice on what to do in
the event of an overdose.
18. On 18 August, Mr Day completed workbooks on relapse prevention and on the risks
of taking heroin and crack cocaine.
19. On 7 September, Mr Day saw his substance misuse worker and completed training
on naloxone (a medication that can rapidly reverse an opioid overdose). The
substance misuse worker told him about the signs and symptoms of an overdose
and how to administer naloxone.
20. On 9 September, Mr Day completed his methadone detoxification programme. The
same day, a substance misuse worker asked him if he would like to be referred to
Derby community drug and alcohol services to support him on his release. Mr Day
declined this offer but said he would accept a supply of naloxone.
21. On 24 November, Mr Day had a video-link meeting with his community offender
manager (COM). She told Mr Day about his licence conditions. They included a
mandatory drug testing condition as well as a condition that Mr Day should engage
with local services to address his drug offending behaviour problems.
22. On 5 December, a substance misuse worker saw Mr Day for a pre-release
appointment. The substance misuse worker reminded Mr Day about lower tolerance
levels after a period of abstinence and about the signs and symptoms of overdose.
Release from HMP Ranby
23. On 8 December, Mr Day was released from Ranby with a supply of naloxone. As Mr
Day was homeless, his COM had found him a temporary room with a local housing
association, Tower Sanctuary.
24. On the day of his release, Mr Day attended his induction appointment at Derby
Probation. The COM completed the induction paperwork and reminded Mr Day
about his licence conditions. The COM told Mr Day that he must engage with
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community drug and alcohol services to address his drug related offending
behaviour. The COM issued Mr Day with his next appointment for 13 December.
25. On 13 December, Mr Day failed to attend his appointment at Derby Probation. The
COM sent Mr Day a warning letter and issued him another appointment for 22
December.
26. On 15 December, the COM arranged for Mr Day to attend an initial assessment
with the local drug and alcohol recovery service on 19 December.
Circumstances of Mr Day’s death
27. On 16 December, a Tower Sanctuary staff member found Mr Day dead in his room.
They called the police who attended and confirmed Mr Day’s death. A Tower
Sanctuary staff member contacted the COM to tell her that Mr Day had died.
Post-mortem report
28. The post-mortem report concluded that Mr Day died of poly drug toxicity (heroin,
pregabalin (an opioid painkiller) and cocaine). It listed pneumonia (a lung infection)
as a contributory factor.
Findings
29. We consider that Mr Day received good support with his substance misuse issues
while he was in prison. Before his release, substance misuse staff warned him
about the dangers of overdose and trained him to use naloxone, which they gave to
him on release.
30. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman August 2023
Inquest
The inquest, held on 23 May 2025, concluded that Mr Day’s death was drug related.
Prisons and Probation Ombudsman 5
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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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