Ian Bains

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Independent investigation into
the death of Mr Ian Bains,
a resident at Ozanam House
Approved Premises,
on 6 November 2023
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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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.
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.
Mr Ian Bains, a resident of Ozanam House Approved Premises (AP), was found hanged
from a tree in a local park on 6 November 2023. He was 56 years old. I offer my
condolences to Mr Bains’ family and friends.
This is the only self-inflicted death of a resident of Ozanam House within the last three
years.
Mr Bains had been released to Ozanam House after a two-year stay at St Nicholas’
Hospital, a mental health unit. He was engaging positively with his community care plan
and attended appointments with both the community mental health team and his
keyworker. While he had some risk factors for suicide and self-harm, there was no
evidence in the time before his death that he was having suicidal thoughts and little to
indicate that he was at increased risk. I consider that Ozanam House AP staff could not
have foreseen Mr Bains’ death.
We make no recommendations.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman July 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 9
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Summary
Events
1. In July 2008, Mr Ian Bains received a life sentence for murder with a 12-year tariff.
Mr Bains had a history of alcohol misuse and related mental health issues but had
engaged with alcohol related programmes in prison.
2. On 3 November 2021, Mr Bains was transferred to St Nicholas’ Hospital under the
Mental Health Act (MHA). St Nicholas’ Hospital reported that, during this time, Mr
Bains had undertaken positive work and that he was assessed as low risk of harm
to self and others.
3. In March 2023, St Nicholas’ Hospital reviewed Mr Bains’ progress and mental state
and authorised a deferred discharge. He was referred to Ozanam House Approved
Premises, for a six-month placement. Mr Bains appeared positive about plans to be
discharged into the community.
4. On 23 October, Mr Bains arrived at Ozanam House and was inducted by staff.
5. On 6 November, Mr Bains was present for the 7.00am room check. He later left
Ozanam House without signing out.
6. At 9.45am, Mr Bains’ sister telephoned his keyworker. She told the keyworker that
Mr Bains had phoned and said that he had a noose around his neck in Jesmond
Dene Park. Staff at Ozanam House reported this to the police, contacted the
community mental health team and attempted to contact Mr Bains.
7. Later that afternoon, police notified staff at Ozanam House that Mr Bains had been
found hanged from a tree in Jesmond Dene.
Findings
8. We are satisfied that there was nothing to indicate that Mr Bains was at increased
risk of suicide and self-harm in the days before his death. Ozanam House staff
appropriately used a Support and Safety Plan (SaSP), as well as other information
and good discharge planning with St Nicholas’ Hospital, to accurately capture and
understand his risk factors and potential triggers.
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The Investigation Process
9. We were informed of Mr Bains’ death on 7 November 2023.
10. The investigator issued notices to staff and residents at Ozanam House informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded. She obtained copies of relevant extracts from Mr Bains’
prison, probation and medical records.
11. An Assistant Ombudsman visited Ozanam House on 29 November and interviewed
three members of staff.
12. We informed HM Coroner for Newcastle and North Tyneside of the investigation.
The Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
13. We contacted Mr Bains’ mother and sister to explain the investigation and to ask if
they had any matters, they wanted us to consider. Mr Bains’ sister asked several
questions that are outside the remit of this investigation and which we have
addressed in separate correspondence.
14. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
15. Mr Bains’ family received a copy of the draft report. They did not make any
comments.
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Background Information
Ozanam House Approved Premises
16. Ozanam House is an independent Approved Premises (AP) funded by the Ministry
of Justice as part of St Vincent de Paul Society’s AP project. Ozanam House is a
psychologically informed planned environment (PIPE). PIPE APs offer expert
psychological input from NHS clinicians to help staff better manage service users
and are intended to support effective movement through a clear pathway of
psychologically informed provision. In addition, residents are expected to register
with a GP.
17. Each resident is allocated a key worker and offender manager to oversee their
progress and wellbeing and ensure that they adhere to their licence conditions and
premises’ rules. Staff are on duty at Ozanam House for 24 hours a day.
Previous deaths at Ozanam House
18. Mr Bains was the first person to take his own life while a resident at Ozanam House
since 2015. Our investigation into the death of the previous resident concluded that
staff at Ozanam House could not have predicted or prevented the man’s death.
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Key Events
19. On 15 July 2008, Mr Ian Bains was sentenced to life in prison for murder with a tariff
of 12 years. Mr Bains had a history of alcohol misuse and completed alcohol related
programmes in prison. Mr Bains also had a history of mental ill health and self-harm
and attempted suicide.
20. In June 2021, Mr Bains was transferred to HMP Liverpool. He lived in their
healthcare inpatient unit, where his mental health quickly deteriorated, and he
experienced psychotic episodes. Between June and August 2021, Mr Bains was
monitored under suicide and self-harm prevention measures (known as ACCT) on
two occasions, after informing prison staff that he believed he was being watched.
His records indicate that he cut his throat during a period of psychosis.
21. On 3 November, Mr Bains was admitted to St Nicholas’ Hospital under section 47 of
the Mental Health Act 1983. Following his admission, Mr Bains was diagnosed with
psychosis.
22. From December 2022, Mr Bains began having escorted leave from hospital, with no
reported issues. (In May 2023, Mr Bains returned to the hospital intoxicated
following a period of unescorted leave, but no further action was taken.)
23. In March 2023, staff at St Nicholas’ Hospital reviewed Mr Bains’ mental health and
authorised a deferred discharge. Hospital staff recommended that Mr Bains should
remain an inpatient at the hospital while waiting for a Parole Board hearing, despite
not meeting the criteria for detention under the MHA. This decision was made to
protect Mr Bains’ mental health as he had told the clinical team that if he were to
return to prison, he would attempt to end his life. Hospital staff also noted that Mr
Bains had demonstrated significant improvement and insight into his mental health.
24. Mr Bains was subsequently referred to a Psychologically Informed Planned
Environment (PIPE) Approved Premises (AP), Ozanam House, for a six-month
placement. (PIPE APs aim to support the progression of offenders with complex
needs and personality-related difficulties.)
25. On 29 June, Mr Bains’ probation officer attended a ‘Section 117 aftercare meeting’
with hospital staff and the Forensic Community Service Team. (FCS, the community
mental health service). They discussed Mr Bains’ community care plan.
26. On 30 August, Mr Bains attended Ozanam House for a familiarisation visit. He was
accompanied by hospital staff. Ozanam House staff gave him a tour of the building
and answered any questions with the aim of helping him feel less anxious about his
transition to the community.
27. On 28 September, a discharge meeting was held at St Nicholas’ Hospital which was
attended by staff from Ozanam House, the Clinical Lead, and the probation officer.
Mr Bains community care plan and risk factors were discussed. Risk factors
included historic self-harm, paranoid beliefs and warning signs of low mood, a lack
of motivation and a willingness to engage. The care plan detailed that Mr Bains had
no thoughts of suicide or self-harm at the time. The meeting did not highlight any
indicators that Mr Bains was currently at increased risk of suicide and self-harm.
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28. On 23 October, Mr Bains was released on licence to Ozanam House. Staff at St
Nicholas’ Hospital proposed a community care plan that included weekly
appointments with the forensic mental health team, ongoing relapse prevention
work, and regular breathalyser tests, as well as continuing to take his medication.
Mr Bains was prescribed medication that included olanzapine (an antipsychotic)
and gabapentin (which treats epilepsy and nerve pain).
Ozanam House
29. Prior to Mr Bains’ arrival at Ozanam House, his allocated keyworker completed a
pre-arrival resident plan and a Support and Safety Plan (SaSP) using information
from Mr Bains’ records. This detailed Mr Bains’ risk factors and warning signs
previously reported within his community care plan. Risk factors included historic
self-harm, drug and alcohol use, a lack of engagement with support or medication
and warning factors included expressing paranoid beliefs, low mood, a lack of
motivation and willingness to engage.
30. Upon arrival at Ozanam House, a Project Support Worker completed Mr Bains’
induction. She reported that Mr Bains presented as cheerful and that he was happy
to be back in the community and was looking forward to moving on. She completed
the SaSP assessment with Mr Bains, who highlighted no concerns around thoughts
of suicide and self-harm. He reported that he was bullied two years prior, which led
to a previous suicide attempt at HMP Liverpool (referring to when he cut his neck).
31. Mr Bains’ induction appointment also included going through his licence conditions
and rules of the AP. Mr Bains’ licence conditions included a condition to reside at
Ozanam House, abide by a curfew of 7.00pm-7.00am and to comply with any
requirements specified by the supervising officer for the purpose of addressing his
alcohol problems. As per AP rules, Mr Bains was also required to comply with drug
and alcohol testing as requested (drug testing is a mandatory condition of Ozanam
House).
32. Ozanam House operates a default high risk assessment for new residents, meaning
that for three weeks additional welfare checks will take place at midnight to ensure
that residents are well. Mr Bains was therefore subject to the usual daily checks and
the additional midnight checks.
33. On 24 October, Mr Bains attended several appointments:
• An induction appointment with his probation officer. She revisited Mr Bains’
licence conditions and noted that the forensic team would speak to Mr Bains to
discuss his mental health needs.
• A post-discharge review with the FCS team from St Nicholas’ Hospital. Mr Bains
met with the Team Manager and Assistant Practitioner. They reviewed Mr
Bains’ mental health and current risks. No changes were noted following his
discharge and they recorded that there was no evidence of his mental health
deteriorating.
• An initial keyworker appointment with his keyworker. She discussed the
activities available in the AP including the requirement that residents attend a
keyworker session, an unstructured activity, and a structured activity each
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week. She also discussed Mr Bains’ SaSP with him. Mr Bains recapped his
previous suicide attempt and shared that he was not aware of any current risk
factors to his mental health. Mr Bains expressed that he was worried about
completing a benefits application and that another AP worker had offered their
assistance. Mr Bains reported no concerns with alcohol, stating that he had
been sober for 16 years and confirmed that he understood that his medication
would remain in the office and be subject to a weekly review. She told us that
she did not challenge Mr Bains regarding his sobriety as she assessed that this
had not been a continuous issue and that the incident in May 2023 had been
isolated.
34. On 25 October, the FCS team reviewed Mr Bains. They recorded that there was no
indication that there had been any changes to his mental health or risks. At the AP,
Mr Bains declined activities and spent most his time in his room.
35. On 26 October, an Assistant Psychologist from St Nicholas’ Hospital reviewed Mr
Bains and reported no indication of any changes to his mental health or risk factors.
Mr Bains declined AP activities and largely remained in his room but responded to
all welfare checks.
36. On 27 October, Mr Bains remained in his room. However, was talkative with AP
staff when he collected his medication and complied with a breathalyser test. The
breathalyser machine was unable to give a reading due to needing recalibration.
Staff reported no signs that Mr Bains had consumed alcohol. (On two further
occasions in the month, staff were unable to test Mr Bains for alcohol due to the
same issue with the breathalyser.)
37. On 28 October, the team manager received Mr Bains’ formal discharge summary
from St Nicholas’ Hospital and shared this with AP staff. The discharge summary
detailed the occasion in May 2023 when Mr Bains returned to hospital intoxicated
after a day of unescorted leave and highlighted that his risk of self-harm was low
but would likely increase if he consumed alcohol. Psychology input, relapse
prevention, medication compliance, random breathalyser tests and involvement with
the FCS were highlighted as methods to mitigate Mr Bains’ risk.
38. On 30 October, Mr Bains had a telephone conversation with a manager, and she
said that she would visit him on 6 November.
39. On 31 October, Mr Bains told AP staff that he was looking forward to seeing a
movie with his brother. The FCS team reviewed Mr Bains and recorded that there
was no indication of any change in his mental health or risks.
40. On 1 November, the keyworker had a keyworker session with Mr Bains, during
which he spoke positively about a visit from his family and expressed that he had no
urges to drink and that he was complying with his medication. Mr Bains also had
appointments with staff members from St Nicholas’ Hospital, who accompanied him
to the local GP surgery to collect a doctor’s note. She helped Mr Bains with his
online universal credit application.
41. On the same day, Mr Bains attended a group reflective practice session with the
AP’s Higher Assistant Psychologist. Mr Bains also spoke to a Project Support
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Worker, who asked whether he felt like he was getting the support he needed, to
which Mr Bains said he was.
42. On 2 November, Mr Bains attended a session on healthy relationships. An Assistant
Psychologist from St Nicholas’ Hospital reviewed him and recorded that there was
nothing of note.
43. On 3 November, Mr Bains told AP staff that he was concerned about his gabapentin
prescription. Mr Bains’ prescription required him to take three 300mg tablets in the
morning and four in the afternoon, but the GP had only prescribed one tablet per
day. The AP Manager quickly resolved this issue and notified Mr Bains, who was
relieved. AP staff encouraged Mr Bains to start eating communally at the AP, which
he said that he would try to do over the coming weekend.
44. On 4 November, Mr Bains participated in bingo with AP residents. A Project
Support Worker reported that he had mostly been in his room and that staff had
provided advice about a better data package for his mobile phone. Mr Bains
planned to discuss this further with her.
45. On 5 November, Mr Bains responded to welfare checks and took his evening
medication. He ordered a takeaway and told staff that he would eat half that day
and the other half the following day.
6 November
46. Mr Bains was present for the 7.00am welfare check. He did not sign out of Ozanam
House, and staff were unable to verify what time he left the premises. Mr Bains did
not speak to any members of staff before leaving the premises.
47. At 9.45am, Mr Bains’ sister called his keyworker and told her that Mr Bains had
called her to say that he had a noose around his neck and was in Jesmond Dene (a
large local park with substantial woodland). She advised Mr Bains’ sister to report
this to the police and simultaneously requested a colleague to report the matter.
48. At 9.50am, the keyworker called Mr Bains, who answered and said that he wanted
to kill himself. She asked if he wanted to return to Ozanam House, where he could
talk about this, but there was bad reception, and the call was cut off. She attempted
to return the call three times, but there was no answer.
49. At 10.00am, the keyworker called the Clinical Team Lead for St Nicholas’ Hospital.
She then emailed Mr Bains’ probation practitioner, informing her of the situation and
action taken. Both the Clinical Team Lead and probation practitioner were unable to
contact Mr Bains as his phone was now switched off.
50. By 12.40pm, the police had arrived at Ozanam House and searched Mr Bains’
room. Later that afternoon, they informed AP staff that Mr Bains had been found
hanged in Jesmond Dene Park after a large-scale search. (We do not know what
time the police found Mr Bains.)
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Contact with Mr Bains’ family
51. On the afternoon of 6 November, police notified Mr Bains’ mother and sister of his
death. On 9 November, the probation practitioner contacted Mr Bains’ mother to
offer her condolences. The AP manager contacted Mr Bains’ sister and advised her
of the financial support available for funeral costs.
52. A manager attended Mr Bains’ funeral on 21 November on behalf of Ozanam
House staff.
53. Ozanam House AP contributed to the costs of Mr Bains’ funeral in conjunction with
HMPPS.
Support for residents and staff
54. The AP manager and a colleague met with residents of Ozanam House to notify
them of Mr Bains’ death and identify support available. AP staff were offered
support collectively and during one-to-one supervision.
Post-mortem report
55. A post-mortem examination found that Mr Bains died from pressure on the neck
due to hanging. Toxicology tests identified the presence of prescription medication
(gabapentin and olanzapine), with no other significant findings.
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Findings
Identifying the risk of suicide and self-harm
56. Mr Bains had several risk factors for suicide and self-harm. He had a recorded
history of attempted suicide in prison and had been monitored under ACCT
procedures on two occasions. Mr Bains had a diagnosis of depressive disorder with
psychotic symptoms following treatment in St Nicholas’ Hospital for two years. Mr
Bains also had a history of alcohol misuse and had relapsed once in May 2023,
during his stay in hospital.
57. Prior to Mr Bains arriving at the AP, staff from Ozanam House and Mr Bains’
probation officer attended a discharge meeting with staff from St Nicholas’ Hospital.
The hospital produced a detailed community care plan which provided information
on key community contacts, frequency of mental health appointments and a risk
management plan that contained both risk factors and protective factors. Within the
hospital’s discharge summary, updated on 23 October but shared with the AP on 28
October, Mr Bains was assessed as low risk of harm to self and others. Mr Bains
was accompanied by hospital staff upon arrival to the AP.
58. Following his arrival at Ozanam House, AP staff considered his history and risk
through his induction, SaSP, resident plan and keywork sessions. Although Mr
Bains denied any thoughts of suicide and self-harm, staff appropriately completed
additional welfare checks in line with local policy.
59. Mr Bains had regular appointments with FCS staff from St Nicholas’ Hospital and
reported that he was happy with the support he was receiving. Mr Bains gave no
indication to AP staff, FCS staff or family that he was at risk of suicide. He appeared
to be settling into the AP, was beginning to participate in AP activities, engaged well
with his keyworker and appointments with the FCS. There was no indication that
any of his recognised triggers were present.
60. Despite there being a delay in the AP staff receiving Mr Bains’ discharge summary
from St Nicholas’ hospital, which included information about Mr Bains’ relapse in
May 2023, this information would not have changed Mr Bains’ risk assessment
levels at the AP. Mr Bains had no other relapses recorded, did not present to AP
staff as under the influence on any occasion during his stay and his toxicology
report did not indicate he had consumed alcohol. Both AP staff and Mr Bains’
probation officer attended Mr Bains’ discharge meeting and were involved with his
discharge planning. AP staff had sufficient information about Mr Bains’ triggers and
risk factors from his community care plan.
61. We are satisfied that AP staff had appropriate understanding of Mr Bains’ risk
factors and potential triggers. We are satisfied that in the days leading to his death
there was nothing to indicate that he was at increased risk of suicide and self-harm
and that it would have been difficult for staff at Ozanam House to have foreseen his
death.
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Good practice
62. We wish to highlight the work undertaken by all staff in preparing for Mr Bains’
arrival at Ozanam House. The AP manager said that Mr Bains was the first resident
they had received directly from a hospital setting. Throughout Mr Bains’ hospital
stay and following discharge, both probation and Ozanam House staff worked
closely with the FCS to ensure Mr Bains’ resettlement into the community.
AP manager to note
63. Alcohol testing was recommended by St Nicholas’ Hospital staff to assist probation
staff in monitoring Mr Bains’ risks of mental health deterioration and risk of harm. It
is a requirement that all residents at the AP comply with drug and alcohol tests.
However, on four occasions the breathalyser at Ozanam House was unable to give
a reading due to needing recalibration. HMPPS informed us that it is the
responsibility of the company providing breathalyser machines to complete
recalibration. The equipment now displays a message for equipment to be
recalibrated every 6 months.
64. It appears that Mr Bains’ discharge summary, dated 23 October 2023, was not
available to AP staff until the 28 October 2023. Although this would not have
changed Mr Bains’ risk assessment, timely information sharing when moving
between establishments is important to enable up to date assessments and care.
Inquest
65. The Coroner’s Inquest opened on 4 December 2024 and concluded on 31 March
2025. The Inquest concluded that Mr Bains died by suicide.
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