Gerard Doyle

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Independent investigation into
the death of Mr Gerard Doyle,
on 24 December 2024,
following his release from
HMP Lancaster Farms
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, 2026
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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 Gerard Doyle died from cocaine toxicity and pneumonia (a chest infection) on 24
December 2024, following his release from HMP Lancaster Farms the day before.
Pulmonary emphysema (a chronic lung condition) also contributed to his death. He
was 42 years old. We offer our condolences to those who knew him.
5. We found that Mr Doyle did not report any concerns about his physical health in the
lead up to, or on the day of his release, from Lancaster Farms.
6. Mr Doyle accessed satisfactory substance misuse support for the duration of his
sentence. However, when he transferred to Lancaster Farms, he was not given
naloxone (used to reverse the effects of an opioid overdose) training or a naloxone
kit upon release. We are pleased that the prison acknowledged this and has already
taken steps to address the issue.
7. Mr Doyle’s community offender manager (COM) appropriately prepared for his
release. They made appropriate accommodation referrals to homelessness support
services. Mr Doyle was released with accommodation in place.
8. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Doyle. We make no recommendations.
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The Investigation Process
9. HMPPS notified us of Mr Doyle’s death on 24 December 2024.
10. The PPO investigator obtained copies of relevant extracts from Mr Doyle’s prison
and probation records.
11. We informed HM Coroner for Liverpool and Wirral of the investigation. He 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 Doyle’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.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
14. Mr Doyle’s family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Preston
15. HMP Preston is a category B prison which holds convicted and remanded male
prisoners. Practice Plus Group provides healthcare, mental health and substance
misuse 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.
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Key Events
HMP Altcourse, 15 January – 22 February
17. On 15 January 2024, Mr Gerard Doyle appeared in court charged with drug supply.
He was remanded to prison and taken to HMP Altcourse.
18. During his first reception screening, Mr Doyle told healthcare staff he was
experiencing withdrawal symptoms from using drugs and had severely aching joints
and muscles. Healthcare staff gave him medication for pain management. Mr Doyle
tested positive for cannabinoids, cocaine and opioids.
19. During a secondary reception screening the following day, healthcare staff
prescribed Mr Doyle 10ml of methadone (a medication used to treat heroin
dependence) with a plan to increase the dose to 40ml. He was also prescribed
diazepam to manage alcohol withdrawal. He told a nurse that he last used drugs
three days prior and reported using six to seven bags of heroin daily for the past
year, along with twelve to fourteen rocks of crack cocaine and up to one litre of
vodka each day during that time.
20. On 20 January, Mr Doyle saw the mental health team and did not report any current
mental health issues. They told him how to self-refer for talking therapy.
21. On 26 January, a nurse recorded that Mr Doyle was managing well on 30ml of
methadone and reported no physical or mental health issues. The nurse conducted
a five-day review for substance misuse monitoring and documented a plan to
continue methadone treatment and stop substance misuse observations.
22. On 12 February, Mr Doyle was convicted and sentenced to 28 months in prison.
23. On 15 February, Mr Doyle told a nurse that he was struggling with his mental health
and wanted to access talking therapy. The nurse recorded that he may have been
under the influence of illicit substances and informed a GP to arrange further
monitoring and observations. The nurse also recorded that Mr Doyle knew how to
self-refer to talking therapy and that the mental health team did not need to provide
any further input.
HMP Berwyn, 22 February – 30 November
24. On 22 February, Mr Doyle transferred to HMP Berwyn.
25. On 6 March, Mr Doyle attended a substance misuse assessment. Mr Doyle told
healthcare staff that he was keen to engage with interventions. He remained on
30ml of methadone. He reported a history of heroin, crack cocaine and
benzodiazepine (often used to treat anxiety and insomnia) misuse. He denied any
alcohol use for the past twenty years.
26. On 14 March, a substance misuse service (SMS) worker asked for Mr Doyle to be
added to the recovery workshop to access support and help him stay motivated.
The SMS worker also noted that Mr Doyle wanted to reduce his methadone dose so
they discussed this with the GP. The SMS worker arranged for Mr Doyle to
complete in-cell workbooks on heroin and crack cocaine use, coping skills, harm
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reduction and relapse prevention. They also referred him to a substance misuse
group intervention and a course to promote positive behavioural changes.
27. On 11 April, Mr Doyle saw a SMS worker who noted that Mr Doyle had reduced his
methadone from 30ml to 25ml with a plan to reduce the dose each week. He
remained on a waiting list for the substance misuse group intervention. On 5 June,
staff removed him from the substance misuse group for missing two sessions.
28. On 5 May, Mr Doyle left a message on a self-service system, stating that he was
struggling with his mental health. The mental health team saw him the next day and
agreed to book him an appointment with the GP.
29. On 7 June, Mr Doyle told a GP that he had Attention Deficit Hyperactivity Disorder
(ADHD – symptoms include impulsivity, hyperactivity, inattention and emotional
disregulation) and had been taking medication for schizophrenia in the community.
The GP asked a nurse to contact his GP in Ireland for further information on his
mental health. The following day, the nurse visited Mr Doyle on the wing, and he
told her he was being released from prison soon and did not want any further
support.
30. On 20 June, a SMS worker noted that Mr Doyle had reduced his methadone to
20ml, reported feeling stable, and wanted to reduce further. He said he was feeling
better and working full-time in the kitchens, which he enjoyed. The SMS worker told
him he would start a four-session course in July covering education and relapse,
making changes, destructive behaviour, and lifestyle balance.
31. On 27 June, Mr Doyle completed six acupuncture sessions. On 21 August, Mr
Doyle asked to reduce his methadone by 3ml from 9ml. Healthcare staff noted that
he had coped well with the reductions. On 26 October, he reduced his methadone
to 1ml.
32. On 7 November, Mr Doyle was released from Berwyn under Home Detention
Curfew (HDC) to an approved premises. (HDC is a form of early release available
to prisoners in England and Wales, which allows them to complete the remainder of
their sentence in the community. Under the scheme, eligible prisoners are released
from custody and remain at home, subject to electronic monitoring and curfew
conditions. Any breach of these conditions may result in their return to prison.)
33. On 14 November, Mr Doyle missed his planned probation appointment. On 19
November, approved premises staff contacted probation to report that Mr Doyle had
not returned to the property since the weekend and they suspected he had removed
his electronic monitoring tag.
34. On 20 November, a probation officer completed paperwork to recall Mr Doyle to
prison for 28 days. The recall was processed and a warrant for his arrest issued on
the same day.
HMP Preston, 30 November – 9 December
35. On 30 November, Mr Doyle was recalled and taken to HMP Preston. During his first
reception screening, a nurse completed clinical observations (which involves
checking body temperature, blood pressure, pulse and breathing rate). They were
within the normal range. Mr Doyle produced a positive drug test result for opiates,
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benzodiazepines, cocaine and cannabinoids. Staff moved him to the segregation
unit due to two positive body scanner results (suggesting he had concealed drugs).
36. On 1 December, Mr Doyle saw a key worker, while in the segregation unit.
(Keyworkers provide prisoners with an allocated officer that they can meet regularly
to discuss how they are and any day-to-day issues they would like to address.) The
key worker said that Mr Doyle would be allocated a key worker to see him twice a
month. Mr Doyle told the key worker that he had no support network in the
community and needed support with his substance misuse issues. The key worker
explained the support available in prison.
37. On 3 December, Mr Doyle saw a resettlement worker. Mr Doyle told her that he was
of no fixed abode (NFA) in Liverpool, he had lost his pin number for his bank cards
and did not have ID or a mobile phone. The resettlement worker agreed to request
ID for him. She noted that Mr Doyle remained in the segregation unit and was not
prescribed any medication for detox as he was still testing positive for illicit drugs.
Mr Doyle told her that he wanted to be referred for substance misuse support in the
community. On 4 December, Mr Doyle moved from the segregation unit to a
standard wing.
38. On 6 December, Mr Doyle saw a nurse who noted that he did not realise that he
was being released later in the month. He asked for a referral to a drug and alcohol
service in Liverpool, which the nurse agreed to do. Mr Doyle confirmed that he
knew about naloxone and how to administer it. The nurse advised him to take
naloxone with him when released.
HMP Lancaster Farms, 9 December – 24 December
39. On 9 December, Mr Doyle transferred to HMP Lancaster Farms. It is not clear why
he moved. Healthcare staff noted that he felt fit and well and was medically fit for
transfer. He had his clinical observations taken and his temperature, blood
pressure, oxygen saturation levels and pulse readings were all within normal range.
40. On 10 December, Mr Doyle’s Prison Offender Manager (POM) referred him to the
mental health team due to his anxiety, depression and past trauma from
bereavements. He saw the mental health nurse the following day who added him to
a waiting list for a talking therapies assessment.
41. The POM also emailed the prison drug and alcohol team, stating that Mr Doyle
wanted to engage with their services and requesting referrals to community
substance misuse support. A healthcare worker saw Mr Doyle that day and
informed him about his reduced tolerance to drugs, risk of overdose and provided
harm reduction advice. They also gave him a referral form if he wanted to engage
with support. He did not access any further support while at Lancaster Farms.
42. On 19 December, Mr Doyle was given a discharge letter to prepare for his release.
On 23 December, Mr Doyle was released from prison.
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Pre-release planning
43. On 28 November, Mr Doyle was allocated a new community offender manager
(COM).
44. On 9 December, the COM referred Mr Doyle to the Community Accommodation
Service Tier 3 (CAS3 - a service open to adult prison leavers who are at risk of
homelessness on release which provides access to up to 84 days of
accommodation.)
45. On the same day, The resettlement worker completed a Duty to Refer to Liverpool
City Council for housing. (Duty to Refer means that when prisoners need a place to
live after being released, prison or probation staff must refer them to the appropriate
services or housing authorities to ensure they have support in finding stable
accommodation.)
46. On 10 December, the POM referred Mr Doyle to Reconnect, a service that helps
prisoners continue accessing healthcare in the community. Reconnect responded
on 18 December, stating they could not see him before his release due to the
limited time available but would refer him to local Reconnect services.
47. On the same day, the POM also referred Mr Doyle to Release Mates (a charity that
supports people leaving prison with reintegration and resettlement). Release Mates
agreed to provide clothing and help Mr Doyle attend appointments on his release
day.
48. On 17 December, Mr Doyle attended a video link meeting with his POM and COM.
They informed him that he had CAS3 accommodation and that Release Mates
would provide clothes, shoes, and food when he was released. Mr Doyle said he
felt in a better place, was ready to engage with probation and substance misuse
services and was happy to have accommodation in Liverpool.
49. Mr Doyle was instructed to attend Bootle Probation Office on the day of his release.
He was aware of his licence conditions.
Post-release management
50. On 23 December, Mr Doyle was released from Lancaster Farms.
51. Mr Doyle attended his probation appointment as required on 23 December at
11.15am. The COM went through Mr Doyle’s induction paperwork with him,
including his licence conditions and he signed to indicate his agreement. The COM
noted that Mr Doyle engaged well during the appointment and seemed motivated to
address his substance misuse issues. He attended probation with two members of
staff from Release Mates, who were due to accompany him to his accommodation.
52. The COM provided Mr Doyle with a bus travel warrant for his next appointment,
scheduled for Monday 30 December at 10.00am. She told Mr Doyle he needed to
get to his accommodation by 1.00pm. He attended the property on time with
Release Mates staff, who stayed with him until 1.32pm.
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Circumstances of Mr Doyle’s death
53. According to police statements, Mr Doyle went to another person’s address on 23
December with a man he knew from prison. Witnesses reported that Mr Doyle fell
asleep on the sofa shortly after arriving and was breathing at that time. The next
morning, 24 December, when others present checked on Mr Doyle again, they
noticed he wasn’t breathing and saw blood at the side of his mouth. At 4.45am,
paramedics attended the property and pronounced Mr Doyle’s life extinct at
5.03am.
Post-mortem report
54. The pathologist concluded that Mr Doyle died from a combination of cocaine toxicity
and pneumonia. Pulmonary emphysema (a lung condition) contributed to his death
and is a known risk for developing pneumonia. Toxicology results showed that Mr
Doyle had consumed a significant quantity of cocaine prior to his death, which
increased the risk of dysrhythmias (abnormal heart rhythm) that can be fatal. The
pathologist also considered an alternative possibility that Mr Doyle may have
suffered dysrhythmias, lost consciousness, and developed pneumonia while
unconscious.
Inquest
55. The inquest held on 7 March 2025, concluded that Mr Doyle’s death was drug-
related.
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Findings
Substance misuse services
56. Mr Doyle took cocaine in a manner consistent with ‘binge use’ prior to his death.
The pathologist concluded that this significantly contributed to his death. While in
prison, Mr Doyle reduced his methadone script as he wanted to be abstinent upon
release. Consequently, he was not prescribed any medication leading up to his
release. Given his history of opioid use, we would have expected Mr Doyle to be
released with a naloxone kit.
57. The Head of Healthcare informed the investigator that following an internal review,
all prisoners with a history of opiate and psychoactive substance use are now
offered naloxone on release from HMP Lancaster Farms. We acknowledge that Mr
Doyle did not take an opioid drug prior to his death, however, we are pleased this
issue has been addressed.
58. Mr Doyle’s POM took appropriate action to address his substance misuse by
referring him to Reconnect in the community. She also ensured that he had support
from Release Mates on his release from prison to ensure he got to his
appointments and had food and clothing.
59. Mr Doyle’s COM also identified that his offending was linked to substance use and
included drug testing and engagement with community substance misuse services
as conditions of his licence.
Clinical care
60. In the days leading up to, and on the day of, Mr Doyle’s release, he did not report
any concerns about his physical health. Healthcare and prison staff did not observe
him to be physically unwell. The Head of Healthcare explained that clinical
observations are not routinely conducted at the point of release unless a prisoner
appears unwell or reports feeling unwell. Staff considered Mr Doyle medically fit to
transfer to another prison on 9 December and medically fit for discharge on 23
December. Mr Doyle did not raise any health concerns during these contacts or
when he subsequently attended his probation appointment.
Accommodation
61. Mr Doyle’s COM prepared appropriately for his release and completed the CAS3
accommodation referral promptly, despite being allocated the case less than a
month before his release. She liaised with Mr Doyle’s POM and ensured Mr Doyle
was told he had accommodation in place before his release.
Adrian Usher
Prisons and Probation Ombudsman November 2025
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