James Howarth

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr James Howarth,
on 29 March 2025, following his
release from HMP Berwyn
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, 2026
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. 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.
3. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
4. Mr James Howarth died from asphyxia caused by airway obstruction due to
aspiration on 29 March 2025, following his release from HMP Berwyn on 20 March.
He was 51 years old. We offer our condolences to those who knew him.
5. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Howarth.
6. We make no recommendations.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
7. HMPPS notified us of Mr Howarth’s death on 14 April 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Howarth’s prison
and probation records.
9. The Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
10. The Ombudsman’s office contacted Mr Howarth’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. They had no
questions but asked for a copy of our report.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Berwyn
11. HMP Berwyn is a Category C resettlement and training prison which holds
convicted male prisoners. It is managed by HMPPS. Betsi Cadwaladr University
Health Board provides 24-hour physical healthcare services.
Probation Service
12. 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.
HM Inspectorate of Prisons
13. The most recent inspection of HMP Berwyn was in January-February 2025.
Inspectors reported that an up-to-date drug strategy document set out joint working
arrangements and the recovery pathway, although it did not include a sufficiently
detailed supply-and-demand reduction action plan. Clinical prescribing from
experienced GPs was in line with national standards while community referrals
were made for prisoners before their release and they were given harm
minimisation advice and training and supply of naloxone (a nasal spray to prevent
overdose) where appropriate.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
Background
14. On 4 December 2024, Mr James Howarth was remanded to HMP Preston charged
with burglary and theft. On 20 December, he was sentenced to eight months in
prison.
15. On 5 February 2025, Mr Howarth transferred to HMP Lancaster Farms. On 13
February he was released on Home Detention Curfew (HDC – where fixed-term
offenders serving between three months and four years in prison may be released
between 15 days and 180 days earlier than their normal release date at the halfway
point of their sentence). However, on 3 March, he breached the conditions of his
licence, and he was recalled to prison and sent to HMP Berwyn. His release date
was 20 March.
16. Nurse A carried out an initial assessment. Mr Howarth said that he had been taking
medication for epilepsy. He also had anaemia and had several vitamin deficiencies.
Mr Howarth was tested for drugs and the result was positive for cannabinoids and
cocaine. Mr Howarth said that he was an intravenous drug user and had been
taking benzodiazepine, methadone, heroin, crack cocaine and cocaine. He said that
that he had no mental health problems and had no thought of suicide or self-harm.
Mr Howarth started a methadone detoxification programme and was prescribed
medication for his medical conditions.
17. The following day, Nurse B saw Mr Howarth for his second health screen. She
noticed that he had a leg ulcer on his right leg and a large, healed ulcer on his left
leg. She referred Mr Howarth to a GP for review and gave him advice about the
services the healthcare team provided.
18. On 7 March, Nurse B saw Mr Howarth and completed an ultrasound imaging test
following concerns about the ulcers on his right leg. Mr Howarth was known to be
an intravenous user who injected in his legs. She referred him to a vascular
specialist and advised him to attend his local walk-in centre following his release for
further treatment.
Pre-release planning
19. On 5 March, Ms A from the resettlement team held a pre-release planning meeting
with Mr Howarth. Mr Howarth said that prior to returning to prison, he was living in a
council owned property and had been residing there for over 10 years. He asked if
he could return to that address on his release. Ms A advised him that she would
contact his Community Offender Manager (COM) to approve this prior to his
release, to ensure that it was suitable. Ms A sent an email to the COM to discuss
referring Mr Howarth to the Commissioned Rehabilitative Service (CRS – the
provision of flexible support to those in the criminal justice system which includes
support to secure suitable accommodation and financial well-being).
20. On 14 March, Ms A confirmed that Mr Howarth was able to move back to the same
address he had previously lived in on release.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
21. On 19 March, Nurse C saw Mr Howarth to treat his ulcers. She advised him to see
his community GP following his release and go to the walk-in clinic for further
wound care.
22. Nurse C referred Mr Howarth to the Discover Drug and Alcohol Recovery Service in
the community, and an appointment was arranged for 4.00pm on 20 March. Mr
Howarth declined training for prenoxad (an injection containing naloxone which
temporarily reverses the effects of opioid drugs such as heroin, methadone,
fentanyl and buprenorphine), naloxone (a safe and quick acting medication that
reverses the effects of an opioid overdose) and nyxoid (a medication used for
emergency treatment in cases of known or suspected overdose of opioid drugs).
23. On 20 March, prior to Mr Howarth’s release, healthcare staff met with him and
advised him about how to manage high risk situations and where to go if he felt
depressed or experienced low moods. He was given advice on coping if he
experienced a relapse and where to go should this happen. They also advised him
on recognising signs and symptoms of overdose. Mr Howarth confirmed that he
fully understood what was discussed with him.
Release from HMP Berwyn
24. On 20 March, Mr Howarth was released from Berwyn.
25. Mr Howarth’s post-sentence supervision conditions were explained to him and he
signed the licence to confirm he understood them. Mr Howarth was given his
methadone script. He was also issued with 12 days’ supply of his prescribed
medications.
26. Mr Howarth reported to the probation office for his initial appointment with the duty
probation officer and they went over his licence conditions and his induction pack.
27. Later that day at 4.00pm, Mr Howarth attended the Discover Drug and Alcohol
Recovery Service as planned.
28. At 1.30pm on 27 March, Mr Howarth attended the probation office and was
screened for drugs in line with his licence conditions. Mr Howarth told the duty
probation officer that his father had died and as a result, he had used crack
cocaine. The duty probation officer instructed him to attend Inspire (a community
drug and alcohol service, which accepts referrals from various sources and tries to
facilitate recovery from addiction).
Circumstances of Mr Howarth’s death
29. On 29 March, two teenage boys found Mr Howarth in a shallow creek near a
wooded area of Alexander Park, Wigan. A significant amount of used hypodermic
needles and drug paraphernalia was in the area, suggesting that it was a well-used
site for drug users.
30. The police attended and found no evidence of third-party involvement in Mr
Howarth’s death. Drug paraphernalia was also found on Mr Howarth. The
paramedics attended and pronounced life extinct at 3:56pm.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Post-mortem report
31. The post-mortem report concluded that Mr Howarth died from asphyxia secondary
to airway obstruction due to aspiration. The intoxicant effects of opioids were listed
as a contributory factor as significant levels of morphine/heroin and methadone
were found in his blood.
Findings
32. Mr Howarth had a history of substance misuse. While it is noted that he participated
in the pre-release planning process and actively engaged with the substance
misuse service in the prison and in the community, it was also envisaged that he
would continue to engage with community services, which would have provided him
with additional support. We are satisfied that both the prison and the probation
services did all they could to support Mr Howarth.
33. We make no recommendations.
34. The initial report was shared with HM Prison and Probation service (HMPPS). A
factual inaccuracy was identified, and this has been amended accordingly.
35. At the inquest held on 8 December 2025, the coroner concluded that Mr James
Howarth’s death was drug related.
Adrian Usher
Prisons and Probation Ombudsman October 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