James Green

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Independent investigation into
the death of Mr James Green,
a resident at Elm Bank
Approved Premises,
on 27 January 2024
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 James Green was found hanged at his home address on 27 January 2024, while a
resident at Elm Bank Approved Premises. He was 40 years old. I offer my condolences to
Mr Green’s family and friends.
Mr Green was the second person in two months to take his own life while resident at Elm
Bank.
Mr Green was released on licence to live at Elm Bank, after four months in prison at HMP
Humber. At Humber, Mr Green engaged positively with the substance misuse and mental
health support. The handover from prison to probation and AP staff in the community was
thorough and included relevant risk and protective factors. Mr Green appeared settled and
engaged at Elm Bank.
While Mr Green had some risk factors for suicide and self-harm, there was little evidence
in the time before his death that he was having suicidal thoughts and little to indicate that
he was at increased risk. 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 September 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ......................................................................................................................... 10
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Summary
Events
1. On 11 July 2023, Mr James Green was sentenced to 20 months in prison for
grievous bodily harm. He had a history of substance misuse, primarily alcohol,
which influenced his offending behaviour, and reported a history of anxiety,
depression, and obsessive-compulsive disorder (OCD). He had attempted suicide
at least once before, by tightening a belt around his neck.
2. On 11 December, Mr Green was released on licence and post-sentence
supervision to Elm Bank Approved Premises (AP).
3. On arrival at Elm Bank, Mr Green completed his induction paperwork with his
probation manager. On 12 December, AP staff completed his Support and Safety
Plan (SaSP), which detailed Mr Green’s history of self-harm. Mr Green reported no
current suicidal ideation.
4. Mr Green attended and complied with appointments throughout his time at Elm
Bank and was due to leave the AP in February 2024 to return to his home address
in Sheffield.
5. On 21 January, Mr Green was present for the morning welfare check. At around
8.00am, he signed out of the AP and said that he was going to watch a football
match.
6. By 7.00pm, Mr Green had not returned to Elm Bank for his curfew. AP staff
attempted to call Mr Green, but there was no answer. At 9.12pm, after further
efforts to locate Mr Green, a senior probation manager authorised his recall to
prison.
7. On 28 January, Mr Green’s sister telephoned Elm Bank and told staff that Mr Green
had died. AP staff contacted 101 to verify this, however there was no official report
of Mr Green’s death at that time.
8. On 29 January 2024, the AP manager contacted South Yorkshire Police, who
confirmed that Mr Green had been found hanged at his home address on 27
January.
Findings
9. We are satisfied that there was nothing to indicate that Mr Green was at increased
risk of suicide and self-harm during his time at Elm Bank, before he absconded.
Staff at Elm Bank had a good understanding of Mr Green’s risk factors and triggers.
The recall process was appropriately initiated and exercised, and we do not think
that AP staff could have reasonably foreseen Mr Green’s actions.
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The Investigation Process
10. We were informed of Mr Green’s death on 30 January 2024.
11. The investigator issued notices to staff and residents at Elm Bank AP informing
them of the investigation and asking anyone with relevant information to contact
her.
12. The investigator visited Elm Bank on 28 February. She obtained copies of relevant
extracts from Mr Green’s probation, prison and medical records.
13. The investigator interviewed three members of staff at Elm Bank on 28 February
and four members of staff via Microsoft Teams in March.
14. We informed HM Coroner for Sheffield of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
15. The Ombudsman’s office contacted Mr Green’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Green’s mother
asked for information regarding the mental health support he received whilst in
prison.
16. 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.
17. Mr Green’s family received a copy of the draft report. They pointed out some
factual inaccuracies. This report has been amended accordingly.
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Background Information
Elm Bank Approved Premises
18. Approved premises (AP, formerly known as probation and bail hostels) mostly
accommodate offenders released from prison on licence and those directed there
by courts as a condition of bail. Their purpose is to provide a supportive and
structured environment. Residents are responsible for their own healthcare and are
expected to register with a GP.
19. Elm Bank is an enhanced AP and therefore accommodates critical public protection
cases and national security division cases. It is one of four APs operated by the
West Yorkshire Probation Area.
Previous deaths at Elm Bank
20. Mr Green was the second person in two months to take his own life while a resident
at Elm Bank. Our investigation into the death of the previous resident concluded
that staff at Elm Bank could not have predicted or prevented the man’s death.
Recall
21. Recall refers to the process of returning to prison an individual who does not follow
their licence conditions. It is the responsibility of the Probation Service to initiate
recall of individuals on licensed supervision through the Public Protection Casework
Section (PPCS).
22. The recall process is set out in the Recall, Review and Re-Release of Recalled
Prisoners Policy Framework. In addition to breaching a licence condition, Probation
practitioners must consider whether the recall threshold has been made based on
an individual’s behaviour or circumstances presented whilst on licence.
23. At the point of initiating recall, it is the responsibility of the police to attend a known
address and arrest the individual.
Home Detention Curfew
24. Individuals who are released subject to Home Detention Curfew (HDC) can have
their licence revoked and be recalled to custody at any time during the HDC period.
Where it appears that there is a failure to comply with the curfew condition; or the
individual’s whereabouts can no longer be electronically monitored at the place for
the time specified in the curfew conditions, an individual is liable to be recalled.
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Key Events
25. On 11 July 2023, Mr James Green was sentenced to 20 months in prison for an
offence of grievous bodily harm. Mr Green had a history of alcohol misuse,
depression and anxiety and had attempted suicide by fastening a belt around his
neck in the community in March 2023 after taking illicit substances. Mr Green was
prescribed sertraline (antidepressant medication) in prison.
26. Mr Green served a short period of time at HMP Hull before being transferred to
HMP Humber on 31 August. At Humber, Mr Green denied any previous suicide
attempts at the reception screening. Mr Green lived on the incentivised substance
free living (ISFL) wing and engaged with the substance misuse team. His prison
offender manager (POM) reported that Mr Green was looking forward to being
released on Home Detention Curfew (HDC). He stated that Mr Green raised no
concerns of suicide or self-harm during any interactions with him.
27. On 1 September, Mr Green referred himself to the mental health team, in which he
detailed that he had received support at Hull and from his doctor in Sheffield. Mr
Green reported very bad anxiety, low mood, worry, panic and that he was
experiencing unusual things “every hour of every day”. Mr Green was added to the
waiting list for low intensity cognitive behavioural therapy (CBT) interventions.
28. On 4 October, the POM completed Mr Green’s AP referral, which included risk
information regarding the impact of substance misuse. He noted that the purpose of
the AP placement was to assist Mr Green in adjusting to life outside of prison and
provide drug/alcohol monitoring. It detailed that Mr Green had been referred to the
Sheffield Talking Therapies service prior to custody and that there were no suicide
or self-harm concerns at present. (At the time, Mr Green had not disclosed that he
had attempted suicide in March and the POM did not therefore mention this in the
referral.)
29. On 24 October, two trainee psychological wellbeing practitioners assessed Mr
Green. Mr Green explained that he had struggled with his mental health since the
age of seven and that he would like to continue with the recommendation of CBT
interventions for OCD.
30. On 6 November, Mr Green had a follow-up appointment with a trainee wellbeing
psychological wellbeing practitioner. Mr Green completed a patient health
questionnaire (a tool used for screening and monitoring the severity of depression)
which highlighted that he was struggling with his mental health and had thoughts of
hurting himself on more than half the days. Mr Green disclosed that he had made a
suicide attempt in March 2023. The practitioner told us that Mr Green said that he
had no current intent to harm himself and that he did not want to end his life. He
said that Mr Green frequently spoke about how he was looking forward to his
release, seeing his family and plans he had to change his life.
31. The next day, the practitioner consulted his manager regarding Mr Green’s therapy
and his previous suicide attempt. It was agreed that he would facilitate weekly
appointments with Mr Green to enable more work to be done before his release. Mr
Green’s previous suicide attempt and questionnaire results were not shared with his
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POM or other prison staff and Mr Green was not placed under suicide and self-
harm prevention procedures (ACCT).
32. On 14 November, Mr Green completed another patient health questionnaire and
again reported thoughts of hurting himself more than half the days.
33. On 28 November, a pre-release meeting was held with Mr Green, prison staff and
Mr Green’s community offender manager (COM). They discussed Mr Green’s
anxiety and current engagement with the mental health team. She suggested a
referral to personal well-being in the community and talked through his licence
conditions.
34. On 30 November, Mr Green had a third session with the practitioner. He completed
the patient health questionnaire and again reported thoughts of hurting himself
more than half the days. In interview, the practitioner said that Mr Green’s score on
the questionnaire did not come down. However, he did not assess this as unusual
as Mr Green needed to access a higher level of interventions that would become
available in the community. He reported that Mr Green expressed no desire to act
on his feelings of hurting himself and therefore, did not assess him to be at an
increased risk of self-harm or requiring ACCT support.
35. On 4 December, the manager of Elm Bank AP and Mr Green’s keyworker
completed an AP Residence Plan which highlighted Mr Green’s alcohol misuse and
mental health as risk factors. This referenced that Mr Green had no current
thoughts of suicide. It also highlighted that Mr Green was prescribed sertraline and
that his treatment would include engagement with Change, Grow, Live (CGL) for
substance misuse and GP support for his mental health. The plan also stipulated an
out of hours (OOH) contingency plan indicating the required steps in the event that
Mr Green did not return for his curfew.
36. On 6 December, the COM completed an AP Residence OOH form highlighting
immediate safeguarding concerns for victims and known adults, mirroring the OOH
contingency plan and highlighting Mr Green’s mental health concerns.
37. On 7 December, Mr Green had a final session with the practitioner. The practitioner
gave him self-help booklets on OCD and cognitive restructuring which were
treatments he could access in the community. They also discussed Mr Green’s
interest in a community referral to mental health services. The practitioner told us
that Mr Green did not wish to be referred at this stage as he wanted to finish his AP
placement and re-engage with mental health support when he returned to his home
address in Sheffield.
Elm Bank
38. On 11 December, Mr Green was released on licence to Elm Bank AP. His licence
conditions included HDC between 7.00pm-7.00am, an alcohol monitoring tag (an
electronic tag which analyses the wearer’s sweat and records if alcohol is present),
exclusion zones and a non-contact requirement with his children and ex-partner. In
addition to the alcohol monitoring tag for six months, Mr Green’s licence stated that
he should not consume alcohol unless permitted by his offender manager. The
COM explained in interview that, in practice, this meant that Mr Green’s alcohol
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consumption would be monitored but that he was not required to be abstinent. Mr
Green’s licence also specified “monitoring only, not abstinence”.
39. Mr Green was met by his community offender manager COM, who completed his
induction pack and gathered his GP details. AP staff also went through his
medication contract for sertraline and other basic information including his next of
kin details.
40. On 12 December, a residential worker completed a second stage induction with Mr
Green, which included discussing GP registration and a Support and Safety Plan
(SaSP, to identify risks including that of suicide and self-harm) assessment. During
the SaSP assessment, Mr Green reported that he had previously had suicidal
thoughts when feeling depressed but said that this wasn’t something that he acted
on. He did not raise any concerns and said that he was keen to get back to work
and to fix his house. The residential worker recorded Mr Green’s previous suicide
attempt in early 2023 and Mr Green stated that this was because of a “bad come
down” from cocaine. Mr Green said that he felt better since taking sertraline
regularly and was motivated to do well.
41. On 21 December, the keyworker completed a SaSP review with Mr Green. He
reported no issues and expressed that he was confident that he would never try to
harm himself in the future.
42. Over the Christmas period, Elm Bank staff noted that Mr Green had increased the
amount of alcohol that he drank. There is no indication that staff discussed this
increased usage with him at the time. (Mr Green’s alcohol tag recorded alerts. This
data was recorded on probation records (Delius) and although this was accessible
by all staff, AP staff would not have been routinely alerted to check.)
43. On 28 December, the keyworker completed a Support Plan with Mr Green (a
document that records risk and need information to enable staff to understand the
resident). This highlighted risk triggers such as negative feelings due to anxiety and
depression; warning signs such as spending more time in his room, looking angry
and bottling things up; harmful behaviours such as drinking or taking drugs, which
Mr Green stated he would not do due to going through the family courts to seek
access to his children.
44. On 10 January 2024, Mr Green had an appointment with his COM. She reported
that he appeared fidgety, which seemed to increase when discussing his alcohol
use. They discussed Mr Green’s increase in alcohol use during the Christmas
period and Mr Green explained that he regularly went out with a friend for drinks. Mr
Green appeared anxious to get back to his house in Sheffield and said that he had
missed his children over Christmas.
45. On 11 January, Mr Green attended a keyworker session with his keyworker. He
appeared positive that his house was ready to move into after him fixing it up and
indicated that he would wait until he returned to Sheffield before contacting a
solicitor regarding contact with his children. Mr Green reported that he had an
“encounter” with another resident at Elm Bank who was experiencing an episode of
alcohol-induced paranoia. Mr Green told her that he did not want to get into trouble.
The other resident left Elm Bank three days later.
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46. On 14 January, Mr Green’s alcohol tag recorded an alert.
47. On 16 January, Mr Green attended an appointment with CGL. He admitted to
having “a few drinks” at the weekend when his friend came over. He reported no
cocaine use. Mr Green said that he was looking forward to leaving Elm Bank (on 5
February) to go back home and said that his medication was working, and his
mental health was okay.
48. On the same day, Mr Green attended a keyworker session with his keyworker. He
said that the alcohol tag alert was due to his sock interfering with the connection. Mr
Green spoke about his plans for when he left Elm Bank and returned home. He
talked about his appointment with CGL earlier that day and reassured her that
drinking would not become a regular occurrence and that he was aware that his
alcohol use was being monitored.
49. On 18 January, Mr Green’s alcohol tag recorded an alert.
50. On 19 January, Mr Green attended an appointment with his COM. He expressed
relief that the resident he had had issues with had moved on from Elm Bank. Mr
Green said that he was having trouble sleeping and believed that he had bipolar
disorder. He said that he would discuss this with the doctor when he moved home.
Mr Green spoke about plans for the future, including work he might do, but said that
he sometimes felt depressed because he could not see his children.
51. Mr Green said that the alcohol alert the previous day was because he had been
drinking with a friend. The COM discussed the dangers of drinking alcohol and
highlighted that this was one of his risk factors. Mr Green said that he felt he was
doing better than in the past. Later that day, Mr Green’s alcohol tag recorded
another alert.
52. At around 7.15pm on 20 January, a residential worker spoke to Mr Green. Mr Green
said that he would attend a football match in Sheffield the next day.
Sunday 21 January
53. Mr Green was present for the 6.00am welfare check and signed out of Elm Bank at
8.00am. A residential worker saw him and wished him luck for the football game.
54. At 7.00pm, Mr Green was not present at Elm Bank for his curfew check. AP staff
attempted to call Mr Green and left a voicemail. They then called to check local
hospitals and emailed both South Yorkshire and West Yorkshire Police.
55. At 7.17pm, staff informed the on-call manager that Mr Green had not returned for
his curfew. She advised staff to allow until 9.00pm for him to return before
considering recall, as there may have been travel problems, his phone could have
run out of battery and Mr Green had so far been of good behaviour.
56. At 7.19pm, a residential worker contacted Mr Green’s sister (recorded on probation
records as a friend), who said that he had been with her in Sheffield for the day and
had left at 5.00pm to catch a coach back to Elm Bank.
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57. At 7.31pm, Elm Bank staff asked the police to conduct a victim check in relation to
Mr Green’s conviction. They also called the victim liaison officer to alert them to Mr
Green’s absence.
58. At 8.49pm, staff tried calling Mr Green again. The call went to voicemail.
59. At 9.07pm, staff informed the on-call manager that Mr Green had not returned to the
AP or made contact. She initiated an ‘out of hours’ recall, which was endorsed by a
senior manager. The recall paperwork detailed actions that staff had taken to
contact Mr Green and his next of kin throughout the evening, as well as his known
vulnerabilities of substance misuse and mental health.
22-29 January
60. On 22 January, the COM progressed Mr Green’s recall paperwork. Mr Green’s
licence was revoked.
61. The COM explained that it is standard practice for the police to attend any known
addresses after recall has been initiated. We do not know if the police took any
steps to locate Mr Green.
62. At around 1.40pm on 28 January, Mr Green’s sister telephoned Elm Bank and
advised a residential worker that Mr Green had died. He advised the manager of
the AP and contacted 101 for more information, but the police had not yet recorded
Mr Green’s death.
63. On 29 January, the manager of the AP contacted South Yorkshire Police, who
confirmed that Mr Green had been found hanged at his house in Sheffield on 27
January. She contacted Mr Green’s mother, his recorded next of kin, who said that
on the day he did not return to the AP, Mr Green feared being recalled and threw
his phone away.
Contact with Mr Green’s family
64. On 1 February, Mr Green’s mother and brother visited Elm Bank. They collected Mr
Green’s belongings.
65. The manager of the AP offered assistance with funeral costs, in line with national
instructions.
Support for residents and staff
66. After Mr Green’s death, no formal debrief was held due to Mr Green’s death
occurring away from premises. Staff were signposted to relevant support services.
67. The AP posted notices informing other residents of Mr Green’s death and offering
support.
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Post-mortem report
68. A post-mortem examination found that Mr Green died from pressure on the neck
due to hanging. Toxicology tests identified the presence of alcohol at 150mg in his
blood and 208mg in his urine, which are consistent with intoxication.
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Findings
Identifying risk of suicide and self-harm
69. Mr Green had several risk factors for suicide and self-harm. He reported a previous
suicide attempt in early 2023, which he explained was due to having taken drugs.
He had a history of alcohol and illicit substance misuse. Mr Green reported
struggling with anxiety and depression for which he was prescribed sertraline. He
also reported struggling with OCD, which he sought support for during custody. Mr
Green’s licence conditions prohibited contact with his children.
70. In custody, Mr Green was engaged with a psychological wellbeing practitioner. In
several patient health questionnaires, Mr Green reported that he had thoughts of
harming himself. In response to this and to enable more opportunity to work with Mr
Green, the practitioner facilitated weekly sessions instead of fortnightly.
71. However, there was no record that the practitioner considered whether Mr Green
would have benefitted from ACCT monitoring. There is no record that the
practitioner shared information about Mr Green’s previous suicide attempt and
suicidal ideation with staff planning for his release. This was a missed opportunity
for staff to explore more structured support in the community and to provide the AP
and his COM with risk related information.
72. The practitioner told us that he assessed that Mr Green was making good progress
with interventions and expressed no desire to act thoughts of self-harm. He
reported that Mr Green frequently spoke about his plans for the future, in particular,
he was keen to be able to see his children again.
73. Prior to Mr Green arriving at Elm Bank, AP and probation staff attended planning
meetings to discuss a plan for supporting him in the community. The plans
highlighted alcohol misuse as being linked to aggressive behaviour and emotional
wellbeing. Mr Green was offered a referral to mental health services in the AP
catchment area by the practitioner, but turned this down, saying he would prefer to
engage with services in Sheffield when he returned there.
74. At induction to Elm Bank, staff completed Mr Green’s SaSP which highlighted
warning signs such as misusing alcohol and not taking medication. During this, staff
asked him about his previous suicide attempt and recorded emotional triggers
which included his children, and warning signs such as bottling things up and
spending more time in his room. Mr Green engaged with AP activities, was open
about his feelings with staff and did not report any significant developments
regarding contacting his children. Mr Green did not report any current thoughts of
suicide or self-harm and appeared happy to be at Elm Bank, with clear plans for his
future.
75. Mr Green did not report needing any support with his mental health during his time
at Elm Bank. He was compliant with his medication, did not display any overt signs
of deteriorating mental health, and continued to report that he intended to engage
with support services when he returned to Sheffield.
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76. We are satisfied that AP staff had appropriate understanding of Mr Green’s risk
factors and potential triggers, including knowledge of his previous suicide attempt.
In the days leading to his abscondment there was little to indicate that Mr Green
was at increased risk of suicide and self-harm, and it would have been difficult for
staff at Elm Bank to have foreseen his death.
Alcohol monitoring
77. Mr Green’s licence included a condition that his offender manager monitor his
alcohol consumption. This had been highlighted as a contributing factor to Mr
Green’s mental health, offending behaviour, his risk to others and himself.
Toxicology tests identified that Mr Green had consumed alcohol before his death.
78. The COM reported that she had worked with Mr Green prior to him being in prison
and he had not had a period in the community where he had abstained from
alcohol, which is why she considered that an alcohol abstinence tag would have
been unsuitable. Mr Green consumed alcohol over the Christmas period, and she
discussed this with him during supervision. In addition to this there were three
recorded alcohol tag alerts in January. Mr Green reported to his COM and his
keyworker that he had been regularly attending football matches and drinking with
friends. AP staff did not witness Mr Green intoxicated and there were no recorded
incidents of harm surrounding Mr Green’s alcohol consumption. In addition, due to
his compliance with Change, Grow, Live (CGL) and keyworker sessions, staff did
not assess his drinking to have increased or that his risk of harm had increased.
79. We are satisfied that probation staff monitored Mr Green’s alcohol consumption in
line with his licence conditions.
Good practice
80. To enable Mr Green to access more support from the mental health team in HMP
Humber before his release, staff facilitated weekly instead of fortnightly
interventions.
81. There is evidence of staff weighing up key risk information and Mr Green’s
compliance before initiating recall. Prior to Mr Green’s arrival at Elm Bank,
probation and AP staff put in place an ‘out of hours’ recall process which listed
several actions and risk information. After Mr Green’s abscondment, staff accurately
followed this process and relayed key risk information to the police, including
requesting victim welfare checks.
Inquest
82. An inquest of Mr Green’s death was opened on 8 February 2024 and concluded on
14 November 2024. the conclusion was that Mr Green’s death was due to suicide.
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