Hughie Hendry

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Hughie Hendry,
on 25 November 2023, following
his release from HMP Doncaster
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 Hughie Hendry died of drug poisoning on 25 November 2023, following his
release from HMP Doncaster two days earlier. He was 50 years old. We offer our
condolences to those who knew him.
5. Mr Hendry had a history of substance misuse and worked with community and
prison drug and alcohol services. After three weeks in prison, he was released
unexpectedly following a video-link court appearance. A prison substance misuse
worker met him before he left the prison and, later that day, contacted Mr Hendry’s
community drug and alcohol team to prepare them for his release and to ensure
continuity of his methadone prescription. It is not uncommon for our investigations
to involve prisoners released unexpectedly with little continuity of care and this was
an example of good practice.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
6. We were informed of Mr Hendry’s death on 4 March 2024. We do not know the
reason for the delay.
7. The PPO investigator obtained copies of relevant extracts from Mr Hendry’s prison
and probation records.
8. We informed HM Coroner for South Yorkshire East District 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 office contacted Mr Hendry’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. She asked why Mr
Hendry was released from prison without accommodation.
10. Mr Hendry’s sister received a copy of the initial report. She notified us of two
inaccuracies which have been amended in this report. She also raised further
issues on the family’s notification of Mr Hendry’s death, which have been addressed
in separate correspondence.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies in the report.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Doncaster
12. HMP Doncaster is operated by Serco. Practice Plus Group provides healthcare
services. These range from reception health checks on arrival and regular GP
services, to help with substance misuse, mental health, chronic or long-term
conditions, podiatry, physiotherapy and optometry.
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 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.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
14. On 2 November 2023, Mr Hughie Hendry was convicted of burglary and theft
offences and remanded to HMP Doncaster to await sentencing. At the reception
health screening, Mr Hendry said that he used cocaine and heroin daily and drank
alcohol two to three times a week. The reception nurse referred him to the prison’s
substance misuse team. Mr Hendry said that he was diagnosed with schizophrenia
but was not currently taking medication for this. The nurse also referred him to the
mental health team.
15. Mr Hendry was prescribed methadone (medication for opiate withdrawal) in the
community. This prescription was continued in prison, on a reducing dose. Mr
Hendry complied with his medication throughout his time in prison.
16. On 3 November, Mr Hendry met with the resettlement team and told them that he
had been living at a friend’s address in the community, but this was temporary. Mr
Hendry said he could not return to the address when he was released and would be
homeless in the Doncaster area.
17. On 7 November, Mr Hendry had a follow up assessment with the Community
Integration Team (CIT – who work collaboratively to coordinate pre-release
planning and support community offender managers to plan resettlement).
18. On 9 November, a substance misuse worker assessed Mr Hendry. He recorded
that Mr Hendry had previously engaged with substance misuse services in the
community. Mr Hendry said that he did not intend to use drugs on release and that
he would attend support groups to help his recovery. He said that he had overdosed
on heroin in August 2023. Mr Hendry said that he did not want to be issued with
naloxone (medication to reverse the effects of opiate overdose) on release. The
substance misuse worker referred Mr Hendry to Doncaster Aspire community drug
and alcohol service. Mr Hendry also said that he had no current concerns about his
mental health and expected to receive a sentence of two to three years.
19. On 10 November, Mr Hendry had an immediate needs assessment with a probation
service officer with the CIT. She recorded that that CIT would refer Mr Hendry to
The Growth Company for support with finance, benefits, and debt.
20. On 21 November, Mr Hendry told prison staff that his methadone dose was
currently keeping him stable. He said that he had a good support network and
spoke to his family via his in-cell phone.
21. On 23 November, Mr Hendry attended a court hearing via video-link. He was given
a two-year suspended sentence and was released from prison.
22. Before Mr Hendry left Doncaster, the substance misuse worker met him and
advised him to attend Doncaster Aspire either that afternoon or the next morning, in
order to ensure continuity of care with his prescribing. Mr Hendry again said that he
did not intend to use drugs on release. The substance misuse worker gave him
harm minimisation information and warned him of the risk of overdose. He emailed
Doncaster Aspire with details of Mr Hendry’s methadone prescription and made a
follow-up phone call to advise them of Mr Hendry’s release and that he may attend
the service.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
23. Following his release, Mr Hendry stayed at a friend’s house. Mr Hendry had been in
prison for three weeks and was expected to receive a custodial sentence. There is
no record that any work was done to identify more permanent accommodation
should he have been released from court.
Post Release
24. On 24 November, Mr Hendry attended Doncaster Aspire. He said that he had used
heroin and cocaine since his release. The substance misuse worker who saw him
recorded that she advised Mr Hendry of reports of contaminated heroin and
pregabalin (medication to treat epilepsy and anxiety which is also used as a
recreational drug) in the town, which had resulted in some recent deaths from
overdose. Mr Hendry took his prescribed methadone and agreed to a six-step
recovery plan.
25. On the same day, Mr Hendry was allocated a community offender manager (COM).
26. On 27 November, probation staff sent Mr Hendry an initial appointment letter to
meet his COM on 30 November. (Mr Hendry died before this appointment.) The
letter was sent to the address at which Mr Hendry was living before he was sent to
prison and was a different address to that which he had given Doncaster Aspire
three days earlier.
Circumstances of Mr Hendry’s death
27. On 25 November, two days after his release from prison, the friend with whom Mr
Hendry was staying found him unresponsive and cold to the touch. She told police
that he had used 80ml of methadone and that pregabalin prescribed to her had
gone.
Post-mortem report
28. The post-mortem report concluded that Mr Hendry died of drug poisoning. The
toxicology examination identified evidence of cocaine use shortly before death.
Methadone was present in the overlapping therapeutic/toxic range. The toxicologist
noted that use of pregabalin may have enhanced the sedative effects of
methadone.
Contact with Mr Hendry’s family
29. The Coroner informed us that he had first contacted Mr Hendry’s next of kin, his
sister, on 29 November. We do not know when or by whom Mr Hendry’s sister was
notified of his death.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
30. Mr Hendry was released from prison on 23 November, having received a
suspended sentence following a video-link court hearing. His release was
unexpected, and prison and probation staff had not had much opportunity to plan,
including finding release accommodation for him. Nevertheless, there was some
good practice around his release. A member of the prison substance misuse team
saw him before he left the prison to give advice on harm reduction and meeting the
community drug and alcohol team. He then both telephoned and emailed the
community drug and alcohol team to prepare them for Mr Hendry’s visit and to
ensure continuity of care with his prescription.
Head of Probation Delivery Unit to note
31. Probation records noted Mr Hendry’s address as the one at which he lived before
he was sent to prison, which was different to the release address he gave
Doncaster Aspire and which was recorded on his prison record. It is unclear
whether his initial appointment letter was sent to the correct address or whether Mr
Hendry would have received this had he not died. The COM said that probation
staff were required to update the address information, but we found this had not
happened. Probation staff could have done more to identify where Mr Hendry was
living when released, to ensure that he received important appointment information.
Inquest
32. The inquest into Mr Hendry’s death concluded on the 15 January 2025. The coroner
confirmed that Mr Hendry died of mixed drug (cocaine, methadone, pregabalin) toxicity.
Adrian Usher
Prisons and Probation Ombudsman June 2025
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE