Isa Sule

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Independent investigation into
the death of Mr Isa Sule, on
19 December 2023, following
his release from HMP Highdown
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
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 Isa Sule died of acute respiratory failure caused by the combined effects of
codeine and paracetamol on 19 December 2023, following his release from HMP
High Down on 14 December 2023. Mr Sule also had fatty liver disease (fat in the
liver which affects liver function) and ischaemic heart disease (caused by narrowed
heart arteries) which contributed to but did not cause his death. He was 45 years
old. We offer our condolences to those who knew him.
5. Mr Sule struggled for many years with mental health issues and substance misuse.
He had been to prison many times before and found the structure there easier to
cope with than life in the community. There were many people within High Down,
the Probation Service, and community organisations who were sensitive to Mr
Sule’s difficulties and tried to help him. Unfortunately, Mr Sule was not able to
overcome the challenges of his final release from prison, and the difficulty obtaining
suitable housing is likely to have been an aggravating factor. Mr Sule took illegal
drugs two days before he left prison and the ready availability of drugs on his wing
could not have been helpful to him, especially with his particular mental health
difficulties.
6. On 17 December, Mr Sule called an ambulance, said that he was suicidal and had
taken 80-90 co-codamol tablets. Paramedics attended but Mr Sule refused to go to
hospital and ran away. On 19 December, due to concerns for his welfare, police
entered his property and found him dead.
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The Investigation Process
7. HMPPS notified us of Mr Sule’s death on 21 December 2023
8. The PPO investigator obtained copies of relevant extracts from Mr Sule’s prison
and probation records.
9. We informed HM Coroner for East London of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
10. We contacted Mr Sule’s sister to explain the investigation and to ask if she had any
matters she wanted us to consider. She did not respond.
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Background Information
HMP High Down
11. HMP High Down is in Surrey. It was re-categorised from a local prison to a training
and resettlement prison in April 2022. Central and Northwest London NHS
Foundation Trust provides physical and mental healthcare services. Substance
misuse services are provided by the Forward Trust.
HM Inspectorate of Prisons
12. The most recent inspection of HMP High Down was in August 2023. Inspectors said
that the levels of violence remained too high and that the main cause was the
widespread availability of drugs, which created high levels of prisoner debt. They
also noted that the rate of positive drug tests was among the highest of all men’s
prisons in England and Wales. Inspectors said they were disappointed that reducing
the availability of drugs was not a higher priority for the prison.
13. Inspectors found that primary healthcare services were well-led and equivalent to
those in the community. Staff held weekly multidisciplinary meetings to monitor
patients with complex needs. However, inspectors noted there was poor medicine
supervision and high non-attendance rates for medical appointments.
Probation Service
14. 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.
HM Inspectorate of Probation
15. The most recent inspection of Hammersmith, Fulham, Kensington & Chelsea
(HFKCW) Probation Delivery Unit (PDU) was in August 2022. Inspectors said that
the quality of work was very poor and rated the PDU as inadequate in all
categories. They said that there was a staff vacancy rate of 43% as well as high
levels of staff sickness, and that almost all staff felt their workloads were
unmanageable. They also said that staff retention was a huge issue, with a third of
staff having left the PDU in the previous 12 months. The inspection was carried out
at a particularly difficult time following on from the COVID-19 pandemic and a major
restructure of the Probation Service nationally. Many of the problems found in
HFKCW PDU were reflected in other London region PDUS at the time.
Assessment, Care in Custody and Teamwork
16. ACCT is the Prison Service care planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise prisoners. As part of
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the process, a care plan which includes support and intervention, should be in
place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. Guidance on ACCT procedures is set out in Prison Service
Instruction (PSI) 64/2011 on safer custody.
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Key Events
17. Mr Isa Sule had many convictions, mainly for burglary and theft, which were
associated with his substance misuse problems. Mr Sule was supervised in the
community by the Probation Service and the Police as part of the Integrated
Offender Management programme (IOM, a programme which identifies persistent
and problematic offenders who are managed jointly by partner agencies working
together). He also had longstanding schizophrenia (a mental health condition which
means a person may not always be able to distinguish their own thoughts and ideas
from reality), and other mental health issues. Mr Sule had been sectioned under the
Mental Health Act several times (although not for several years). He sometimes
sought imprisonment as an alternative to being homeless and living life on the
streets.
18. On 2 June 2021, Mr Sule was sentenced to 34 months in prison for burglaries and
for assaulting a police officer when he was arrested. He was released on licence on
15 July 2022.
19. Following his release, Mr Sule relapsed immediately into substance misuse, and
along with spiralling mental health problems, non-compliance with his medications,
not abiding by the terms of his accommodation, and an assessed high risk of
reoffending, on 12 August, the Probation Service decided to recall Mr Sule to
prison. On 15 August, he was taken HMP Wormwood Scrubs and transferred to
HMP High Down on 23 August.
20. On returning to prison, Mr Sule said that he had been smoking heroin three times a
week and had been spending about £200 a day on crack cocaine. The substance
misuse services (SMS) in prison, put Mr Sule on a drug rehabilitation programme.
This included sessions with a dedicated SMS worker and methadone treatment for
opioid addiction.
21. On 27 August, prison officers searched Mr Sule’s cell and found multiple items
hidden in his socks which were suspected of being laced with Psychoactive
Substances (PS). They were taken away for analysis, but the outcomes of tests
were not recorded.
22. However, Mr Sule had a prior history of PS use in prison, and his SMS worker
talked to Mr Sule on several occasions about the risks of substance misuse and
strategies to stay safe. In a meeting on 3 October, she discussed with him the
particular risks of his schizophrenia and the dangers of substance misuse
contributing to psychotic episodes.
23. Mr Sule had frequently self-harmed on previous prison sentences. On 27 October,
he made cuts to his arm in reaction to not being able to get vapes and feeling under
threat. Staff opened an ACCT which they closed the next day. This was the first of
four ACCTs during his time at High Down.
24. On 24 May 2023, staff opened another ACCT as Mr Sule said he felt suicidal and
was hearing voices in his head. Shortly afterwards, he also made cuts to his arm. A
prison officer who had 15 years’ experience with Mr Sule, said his mental state was
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the worst she had seen in all that time. Mr Sule said he had been selling his
schizophrenia medication in order to buy vapes. Staff closed the ACCT on 20 June.
25. Mr Sule continued to hear voices over the following months. He said he felt scared
and paranoid and refused his methadone and mental health medication on 20 and
22 August. On 23 August, staff opened another ACCT as Mr Sule said that the
voices in his head were telling him to hang himself. Staff closed the ACCT six
weeks later.
26. In October, Mr Sule who had asked to be on a reducing dose of methadone,
succeeded in stopping taking it. On 3 November, he told a doctor that he thought
coming off methadone had worsened his mental health and the voices in his head.
The doctor changed Mr Sule’s medications for his schizophrenia and by the end of
the month, he told a mental health nurse at High Down that the voices had
decreased significantly.
27. As Mr Sule’s release from prison drew closer, he became anxious about where he
would live. On 11 December, Mr Sule made cuts to his arm after not being able to
get a vape due to wing lockdown. Staff opened an ACCT.
28. On 12 December, Mr Sule was unable to attend an ACCT review because he was
under the influence of PS. He told his SMS worker that he had taken the drug
because he felt stressed about being released and because of poor decision
making when he was offered it in a social situation.
29. On 13 December, a supervising officer (SO) held an ACCT review with Mr Sule. He
said that he regretted cutting himself and was extremely excited about his release
the next day. He said that he was being picked up at the prison and being taken to
an approved address. He said that he was going to make a new start, get a job and
live his life “the right way”. The SO closed Mr Sule’s ACCT.
30. The next day, before he was released, staff did a post-closure ACCT review with Mr
Sule who said he was excited about being released and seeing his family. He said
he had no thoughts of suicide, and these thoughts were as a result of being in
prison which would no longer be an issue. Staff noted that he was in good spirits
and had no concerns about him.
Pre-release planning
31. Mr Sule’s vulnerabilities were clearly identified and well known, and he had a lot of
input from different people during his time at High Down and in the planning leading
to his release.
32. On 27 September, a member of the prison resettlement team met with Mr Sule to
discuss arrangements for his release. He said he was worried about being
homeless and if that happened he might commit a crime in order to be returned to
prison. The resettlement worker contacted Mr Sule’s Prison Offender Manager
(POM), to alert them of Mr Sule’s need to arrange his release housing.
33. On 29 September, Mr Sule’s SMS worker, his resettlement worker, his care co-
ordinator from the Mental Health In-Reach Team, and a psychiatrist, met and
discussed arrangements for Mr Sule’s release from prison. The meeting was
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followed up with contact with Mr Sule’s Community Offender Manager (COM), to
establish details of previous support in the community and to confirm the area he
would be returning to.
34. On 26 October, Mr Sule’s SMS worker met with him to discuss his release plan. Mr
Sule said that he had not heard anything about his accommodation yet, and his
SMS worker contacted his resettlement officer and care-coordinator. The care-
coordinator contacted the COM about the referrals he had made to the local council
about Mr Sule’s rehousing.
35. On 17 November, a careers information, advice and guidance adviser from High
Down met Mr Sule to discuss practical arrangements with him about work and bank
accounts once he left prison.
36. On 21 November, a new COM took over Mr Sule’s case. Fortunately, she had prior
experience of Mr Sule, knew him well and was proactive in managing his case. She
contacted the POM to liaise with Mr Sule about completing a supported housing
application. She also contacted the IOM officer to arrange a joint meeting with Mr
Sule so that he would be aware of the arrangements following his release from
prison.
37. On 23 November, because of Mr Sule’s history of quickly relapsing into opioid use
on release, his SMS worker discussed with him the possibility of him retoxing onto
an opioid substitute medication to lessen the chances of overdosing when he left
High Down. However, after a few days of reflection, Mr Sule decided that he did not
want to.
38. On 24 November, Mr Sule’s SMS worker said she had arranged for Mr Sule to be
met at the prison gate on release by Forward Trust staff who would take him to his
appointments that day. One of the appointments would be with the community SMS
(Turning Point) staff, who would come and meet him at High Down before his
release.
39. On 4 December, Mr Sule’s SMS worker contacted a housing officer at St Mungo’s
(a homelessness charity) as a back-up in case there was no confirmed housing
arrangement for Mr Sule on release.
40. On 7 December, Mr Sule’s mental health care coordinator contacted the local
council to check on progress towards his accommodation. They confirmed that they
were aware of his impending release and the urgency of his case but had not
allocated it yet.
41. On 8 December, the COM contacted the community mental health services to
inform them that Mr Sule would need support on release. However, she told the
investigator that she did not get a response from them.
42. Mr Sule spoke to his family on the telephone on a fairly regular basis. His last
phone call to his brother was on the 9 December. They spoke about his plans for
release, to which Mr Sule was looking forward.
43. Despite all the efforts from several people, it was not possible to source supported
housing for Mr Sule before his release. On 13 December, the COM informed the
prison that CAS3 housing in North London was confirmed for Mr Sule. CAS3 is
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short term accommodation with low level support which can be made available to
prisoners on release who would otherwise be at risk of being homeless.
44. Mr Sule was released from prison on Thursday 14 December, instead of his due
date of 15 December, under the Discretionary Friday/pre-Bank Holiday Release
Scheme (recently introduced to reduce the difficulties for vulnerable people of being
released on a Friday and immediately facing a weekend when fewer support
services are available). He was given a week’s supply of medications (and his
clinical summary was sent to his GP), and naloxone (a medicine that rapidly
reverses an opioid overdose).
Post-release management
45. Mr Sule was met at the prison gate by Forward Trust staff, who took him to his
meeting with his COM, and also to his SMS meeting with Turning Point.
46. Unfortunately, on the day of his release, the CAS3 housing provider said that the
Probation Services Officer (PSO) from the Homelessness Prevention Team, had
submitted the acceptance of the housing offer (a requirement of securing CAS3
accommodation) after their cut off time, so that it would no longer be available that
day. The PSO explained that the Discretionary Friday/pre-Bank Holiday Release
Scheme had increased the pressure on Thursday referrals and there were too
many on 13 December for them all to be completed on time. He was told that the
accommodation would be available from the next day.
47. As a referral to the local authority had previously been made, the only option
remaining on 14 December, was to go to the Homelessness Unit at Kensington
Town Hall. The person from Forward Trust who had accompanied Mr Sule from
prison took him there. Someone else from Starting Over (an organisation linked to
Turning Point) stayed with Mr Sule all afternoon and evening to ensure that he did
not end up on the streets, homeless. At the end of the afternoon Mr Sule was given
an address in Rainham in the far east of London.
48. When Mr Sule and the person from Starting Over arrived at the property in
Rainham, they found that it was freezing cold and had no bedding. Starting Over
arranged for Mr Sule to spend a night in a hotel. The next day he went to his CAS3
accommodation (a flat in north London).
49. On 15 December, Mr Sule’s COM spoke with him. Mr Sule said he did not know
what to do and might commit another crime so he could go back to prison.
50. On 16 December, Mr Sule’s licence expired, so the COM would have no further
input after that time and Mr Sule was not required to report to Probation. However,
Mr Sule would have continued to be monitored by the IOM Officer and Turning
Point staff would have contributed to the weekly meetings. Mr Sule’s COM
contacted his mental health care coordinator at High Down to update her. The care
coordinator contacted the community housing and health services in an attempt to
arrange support for Mr Sule as she was concerned about his vulnerability due to his
schizophrenia. She was still pursuing this on 19 December, by which time Mr Sule
had died.
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Circumstances of Mr Sule’s death
51. At around 7:30pm on 17 December, Mr Sule called an ambulance and said that he
was suicidal and had taken 80-90 co-codamol tablets (not medication he was
released from prison with). Paramedics attended, but Mr Sule refused to go to
hospital and ran away. Police searched the area at the time but could not find him.
52. Because of concerns for Mr Sule, police entered his property on the morning of 19
December, where they found him dead. There were empty co-codamol packets in
the room consistent with him taking the quantity he had said.
Post-mortem report
53. The pathologist concluded that the cause of Mr Sule’s death was acute respiratory
failure caused by combined drug use of codeine and paracetamol (which are both
contained in co-codamol). Mr Sule also had fatty liver disease (fat in the liver which
affects liver function) and ischaemic heart disease (caused by narrowed heart
arteries) which contributed to but did not cause his death.
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Findings
Management of risk
54. Mr Sule’s mental fragility and vulnerability was understood by the many people
involved in his support. There is extensive evidence in his records of people within
High Down, the local Probation Service, and beyond, trying very hard to help him.
Although staff noted that he would need supported housing on his release, this was
not available. However, even in previous supported housing placements, the
presence of other drug users soon undermined Mr Sule’s abstinence from
substance misuse, and he also had a record of not taking his mental health
medications.
55. The quality of Mr Sule’s last ACCT at High Down just before he was released was
poor. The Deputy Governor commissioned an internal review into this. The results
were not available at the time of writing, but we make no further recommendation.
56. The circumstances leading up to Mr Sule’s release could not have helped his
mental state. In particular the uncertainty of where he was going to live, the self-
harm on 11 December, and the substance misuse on 12 December. This would
have been compounded by the dislocated arrangements on 14 December, with Mr
Sule ultimately ending up a long way from his family on the other side of London.
His COM said on that day he was constantly hearing voices, and the person from
Starting Over who was with him all afternoon and evening said he was very
paranoid and struggling to cope. She thought that he must have felt very isolated in
the accommodation he was put in.
57. As with many other post release deaths we have investigated, Mr Sule was
someone who, while he encountered difficulties with prison, found the structured life
there often easier to cope with than living in the community. Although we do not
know what Mr Sule’s true intentions were on 17 December, he did say to the
emergency services that he had attempted suicide and he had expressed suicidal
thoughts in the past, including during his latest sentence. However, our
investigation found that staff at High Down and his COM had done their best to help
him.
The availability of drugs at High Down
58. Mr Sule said that he took PS on 12 December because it was offered to him, and
he often acted impulsively. Particularly as a result of his schizophrenia and mental
health issues, this could not have been helpful preparation for release two days
later.
59. In the month before he was released from High Down, there were dozens of
incidents of people on his wing being intoxicated through substance misuse,
particularly PS. The HMIP inspectors highlighted this as a particular concern, and
such a ready availability of illicit drugs can only undermine the efforts of the Forward
Trust to help those with substance misuse problems at the prison.
60. The investigator contacted High Down for information on progress in tackling the
availability of drugs in the prison. The Head of Security and the Head of Drug
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Strategy replied and detailed several new initiatives as well as the reinforcement of
existing ones. For operational reasons, some of these cannot be discussed publicly.
However, protocols on PS are being rewritten by the Head of Drug Strategy, which
will combine reduction in supply, with more activity for prisoners to decrease lapse
into drug use through boredom, as well as isolating prolific users from the general
prison population. The incentivised substance free living (ISFL) unit is being
revamped and this should provide greater protection from relapse for prisoners who
want to remain drug free.
61. The Head of Security said that there are more intelligence led searches and drug
testing of prisoners. Staff are also regularly searched. She said that the testing of
mail into the prison continued and now included official mail. Because of the
geography of High Down’s location, the prison has had a long-term problem with
drugs being thrown over the perimeter fencing. She said that High Down has extra
patrols to detect throw overs and is planning to install equipment to improve
detection and deterrence of them. Prisoner access to vulnerable areas is subject to
vetting and High Down continues to work with the police to tackle substance
misuse.
62. The Head of Security provided statistics to show a significant reduction between
November 2023 and January 2024 in the number of incidents of prisoners reported
under the influence of PS and a significant increase over the same period in the
number of drug finds in the prison. We therefore make no recommendation in this
regard.
Note to Regional Probation Director
63. Mr Sule’s CAS3 accommodation application could not be processed in time for his
release one day earlier than scheduled in line with the Discretionary Friday/pre-
Bank Holiday Release Scheme. Staff said that there is now a significant pressure
on Thursday referrals. We draw the Regional Probation Director’s attention to this
issue to ensure that the service provision is adequately resourced.
Adrian Usher
Prisons and Probation Ombudsman July 2024
Inquest
64. The inquest into Mr Sule’s death finished in February 2025 and reached an open
conclusion (meaning that the evidence presented did not fully or clearly explain how
Mr Sule died).
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