James Maughan

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Independent investigation into
the death of Mr James Maughan,
a resident of Trent House
Approved Premises,
on 11 February 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
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
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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 Maughan died in a road traffic accident on 11 February 2024, while a resident at
Trent House Approved Premises. He was 27 years old. I offer my condolences to his
family and friends.
We did not identify any significant learning for HMPPS and 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 November 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
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Summary
Events
1. On 7 March 2021, Mr James Maughan was sentenced to 15 months in prison for
dangerous driving and sent to HMP Lancaster Farms. His Community Offender
Manager noted that his drug and alcohol misuse was linked to his offending
behaviour.
2. On 3 July 2023, Mr Maughan’s Community Offender Manager completed a referral
for him to live in an approved premises (AP) on his release.
3. On 11 January 2024, Mr Maughan was released on licence from prison. His licence
conditions required him to complete mandatory testing for drugs and alcohol.
4. On 11 February 2024, Mr Maughan was seen driving dangerously in Lincolnshire
which is over 40 miles away from Trent House. The police stated that he appeared
to have misjudged a bend and crashed into oncoming traffic. Mr Maughan died at
the scene. Post-mortem toxicology tests found no evidence of drugs in Mr
Maughan’s system and were inconclusive about whether he had consumed alcohol.
Findings
5. Staff at Trent House responded appropriately and initiated Mr Maughan’s recall
process when he was late for his curfew on the night he died. They had never seen
him driving a car.
6. Mr Maughan had not been subject to any drug or alcohol tests in the month he lived
at Trent House.
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The Investigation Process
7. HMPPS notified us of Mr Maughan’s death on 13 February 2024.
8. The investigator obtained copies of relevant extracts from Mr Maughan’s prison and
probation records.
9. The investigator interviewed Mr Maughan’s Community Offender Manager. The
investigator visited Trent House Approved Premises on 22 May 2024 and spoke to
the approved premises manager and Mr Maughan’s key worker.
10. We informed HM Coroner for Greater Lincolnshire of the investigation. He gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
11. The Ombudsman’s office contacted Mr Maughan’s wife to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not have any
questions but asked for a copy of our report.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
13. Mr Maughan’s wife received a copy of the draft report. She raised issues that do
not impact on the factual accuracy of this report and have been addressed through
separate correspondence.
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Background Information
Trent House Approved Premises
14. Approved premises accommodate individuals released from prison on licence and
those on bail or community sentences. Approved premises help monitor the risk of
residents and aim to provide a supportive and structured environment.
15. Trent House is an approved premises in Nottingham. Residents have their own
rooms and are allocated key workers who support them with their progress and
wellbeing. Key workers help to make sure residents comply with the rules of the
approved premises and their licence conditions. Approved premises staff are on
duty at Trent House 24 hours a day.
Previous deaths at Trent House Approved Premises
16. Mr Maughan was the third resident to die at Trent House since February 2021. One
of the two previous deaths was from COVID-19, and the other was a homicide.
There are no similarities between our findings in the investigation into Mr
Maughan’s death and our investigation findings for the previous deaths.
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Key Events
17. On 7 March 2021, Mr James Maughan was convicted of dangerous driving and
sentenced to 15 months in prison. On 30 March 2021, while in custody, Mr
Maughan was convicted of a further offence of grievous bodily harm, for which he
was sentenced to 27 months in prison.
18. Mr Maughan was transferred to HMP Lancaster Farms on 19 October 2022. During
his initial health screen, he disclosed a history of substance misuse.
19. On 20 October, Mr Maughan saw the substance misuse team as part of his
induction to prison. However, he declined a referral to the substance misuse team
and did not want to engage with them. He was given advice about how to refer
himself.
20. In May, Mr Maughan tested positive three times for opiates, psychoactive
substances, and gabapentin (a medication he had not been prescribed).
21. On 15 May 2023, Mr Maughan referred himself to the substance misuse team, as
he wanted to address his cannabis use.
22. On 3 July 2023, Mr Maughan’s Community Offender Manager completed a referral
for him to live in an approved premises on his release. The referral stated that Mr
Maughan needed to be tested weekly for drugs and alcohol.
23. On 4 July, Mr Maughan tested positive for opiates and gabapentin. He said that it
was a one-off use.
24. On 29 August, Mr Maughan told a nurse that he bought mirtazapine from prisoners
as it helped him sleep.
25. On 7 November, Mr Maughan’s previous Community Offender Manager completed
an Offender Assessment System (OASys) form which linked Mr Maughan’s drug
use to serious harm and his offending behaviour.
Trent House AP
26. On 11 January 2024, Mr Maughan was released from Lancaster Farms to Trent
House Approved Premises. That day, Mr Maughan was allocated a new Community
Offender Manager (COM). Mr Maughan’s licence conditions required him to attend
probation to give a sample for drug testing. The licence did not set out the
timeframe or frequency for testing to take place.
27. When he arrived, Mr Maughan was given a drug test kit to complete but he failed to
return it, and no one at the approved premises followed this up.
28. On 12 January, Mr Maughan reported to Nottingham probation office, where he had
an initial supervision appointment with his COM. Mr Maughan appeared motivated
to comply with his licence conditions and completed his induction.
29. On 14 January, Mr Maughan breached his 7.00pm curfew. He phoned the approved
premises staff and told them that he would be late. The COM discussed his delay
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with him during an appointment on 17 January, and he was given a verbal reminder
not to be late for his curfew again.
30. On 17 January, in an appointment with his COM, Mr Maughan said that he would
not use cannabis as he was staying at the approved premises. He said that he used
cannabis to treat the symptoms of his undiagnosed ADHD. He also told his COM
that he was not drinking alcohol.
31. On 23 January, the COM visited Mr Maughan at Trent House. They discussed Mr
Maughan’s accommodation and curfew times. She told him that she had referred
him to Nacro (a charity that provides housing services to individuals leaving
custody), and they would be in contact with him soon.
32. On 31 January, the COM emailed Trent House’s administrative inbox and Mr
Maughan’s key worker, to ask whether he had been tested for drugs (he had not).
No one responded. Trent House’s manager told us by email that the email was not
sent or copied to him so he could not have replied. The key worker told us that he
had overlooked the email due to workload pressure and building works at the time,
and the duty staff at Trent House should have replied.
33. The COM saw Mr Maughan again on 9 February. Mr Maughan appeared frustrated
about the curfew times. She told the investigator that Mr Maughan had wanted his
curfew to start later in the morning and finish later at night.
Circumstances of Mr Maughan’s death
34. On 11 February 2024, Lincolnshire Police informed the approved premises
manager that Mr Maughan had died in a road traffic accident. At approximately
5.45pm, Mr Maughan had been seen driving dangerously at high speeds in
Lincolnshire which was over 40 miles from Trent House. The police stated that he
appeared to have misjudged a bend and collided head on with an oncoming
vehicle. At the point of impact, the car he was driving was on the wrong side of the
road. He was pronounced dead at the scene and a passenger died the following
day. An unopened bottle of whisky was found in the car.
35. By the time the police contacted Trent House, the approved premises manager had
already triggered Mr Maughan’s recall process as he was late for his curfew.
Support for residents and staff
36. After Mr Maughan’s death, Trent House’s manager debriefed the staff at Trent
House to ensure that they had the opportunity to discuss any issues arising, and to
offer support. He also offered support to the residents of Trent House. The COM
was also offered support.
Post-mortem report
37. The post-mortem report concluded that Mr Maughan died of hypervolemic shock
(severe blood loss which causes the heart to be unable to pump enough blood to
the body, leading to organ failure), caused by multiple traumatic injuries. Post-
mortem toxicology results identified the presence of ethanol in his body at a level
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consistent with social use. However, the pathologist noted that the ethanol may also
have resulted from post-mortem changes. The level of ethanol was within the legal
limit for driving. The toxicology results identified the presence of mirtazapine and
pregabalin (which had not been prescribed) at therapeutic levels.
Inquest
38. At an inquest held on 4 February 2025, the Coroner concluded that Mr Maughan
died from a road traffic collision.
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Findings
39. Mr Maughan had been a resident at the approved premises for one month when he
died in a road traffic accident. He had a history of driving-related offences. Mr
Maughan’s licence conditions did not restrict him from driving, and staff at the
approved premises and his Community Offender Manager had never seen him
driving a car. We found evidence that staff at the approved premises responded
appropriately when he returned late to the approved premises and started recall
processes when Mr Maughan did not return to Trent House before his curfew time
on the night he died.
40. Although Mr Maughan’s post-mortem toxicology tests indicated the presence of
ethanol in his system and an unopened bottle of whisky was found in the car he
was driving at the time of his death, the pathologist could not establish whether he
had drunk alcohol before his death as the ethanol may also have resulted from
post-mortem changes. Therapeutic levels of medications that had not been
prescribed to Mr Maughan were also found.
Regional Probation Manager to note
41. Although toxicology tests did not identify that Mr Maughan had taken illicit drugs
before his death, they did identify that he had taken medication not prescribed to
him. His licence conditions included a requirement to test him for Class A and Class
B drugs. Although no timeframe was specified in his licence for this to be done, he
was not tested once in the month after his release from prison.
42. We note that when the COM completed a referral for Mr Maughan to live at an
approved premises, she asked for him to be subject to weekly drug testing.
Although the drug testing formed part of his licence requirements, the weekly
timeframe was not included. A set timeframe for testing would have ensured regular
testing was completed.
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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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