Jamie Graham

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Independent investigation into
the death of Mr Jamie Graham,
on 3 April 2025, following his
release from HMP Durham
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, 2026
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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 investigated 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 Jamie Graham died from an acute cardiac arrest caused by taking synthetic
cannabinoids and cocaine on 3 April 2025 following his release from HMP Durham
on 31 March 2025. He was 28 years old. We offer our condolences to those who
knew him.
5. Mr Graham accessed substance misuse support during his time in prison and
received advice about the risks of using illicit substances while in prison. Mr
Graham’s community offender manager (COM) appropriately prepared for his
release. They made accommodation referrals to homelessness support services
and liaised with the local council, which advised Mr Graham to present for housing
support upon release. Mr Graham did not attend, and as a result, was unable to
access further housing support or a housing assessment. We are satisfied that the
COM took reasonable steps to source accommodation before his release.
6. We did not identify any significant learning relating to pre-release planning or post-
release supervision of Mr Graham requiring a recommendation.
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The Investigation Process
7. HMPPS notified us of Mr Graham’s death on 9 April 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Graham’s prison
and probation records.
9. We informed HM Coroner for Gateshead and South Tyneside of the investigation.
He 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 Graham’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Durham
12. HMP Durham holds convicted male prisoners. Spectrum Community Health CIC
provides healthcare, mental health and substance misuse services.
13. 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
appropriate. Post-release, the Probation Service supervises people throughout their
licence period and post-sentence supervision.
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Key Events
14. On 20 December 2024, Mr Jamie Graham appeared in court, charged with
possession of a knife, was remanded to prison and taken to HMP Durham. On 13
January 2025, he was convicted and sentenced to 20 weeks imprisonment. His
licence and sentence were due to expire on 11 May 2025.
15. On 21 January, the COM was allocated as Mr Graham’s community offender
manager (COM). On 24 January, the COM wrote Mr Graham a letter to introduce
himself and inform him that either he or the pre-release team would be in contact
with Mr Graham before his release.
16. On 29 January, Mr Graham transferred to HMP Northumberland. No issues were
identified during his reception screenings, and he was seen by the drug and alcohol
recovery team. He had a history of using cocaine and synthetic cannabinoids while
in the community.
17. On 3 February, Mr Graham met his recovery coordinator for an initial substance
misuse assessment. They referred him to community substance misuse services.
Mr Graham disclosed that he was homeless and lacked a support network. He said
that he would not accept hostel or shared accommodation and would only consider
housing if it was his own tenancy. He told the recovery coordinator that he preferred
to return to his homeless community in Gateshead, where he had routine and
connections, and did not want to return to his local area due to his risk of
reoffending.
18. On 4 February, the COM referred Mr Graham to an Approved Premises (AP), which
provide 24-hour staffed accommodation for individuals released on licence and
assessed as posing a high risk of harm. The following day, the application was
rejected.
19. On 6 February, the COM referred Mr Graham to the Community Accommodation
Service Tier 3 (CAS3 - a service open to adult prison leavers who are at risk of
homelessness on release which provides access to up to 84 days of
accommodation.)
20. On 13 February, Mr Graham was released from prison with CAS3 accommodation.
Mr Graham failed to attend his probation appointment or contact his COM that day.
21. On 14 February, the COM confirmed that he did not attend his CAS3
accommodation. The COM completed paperwork to recall Mr Graham to prison for
14 days.
22. On 19 February, Mr Graham was sentenced to 28 days in prison for a drug offence
and taken to HMP Durham. During his first reception screening, he tested positive
for cocaine and denied alcohol misuse. The next day, he declined support from the
drug and alcohol recovery team, stating he had not used substances.
23. On 3 March, Mr Graham was released from prison and instructed to report to South
Tyneside probation office. He attended Gateshead probation office, stating he did
not want to go to South Tyneside. He agreed to see his COM the following day but
did not attend.
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24. On 10 March, the Probation Service received notification that Mr Graham had been
arrested the previous day for being drunk and disorderly. Following his arrest, he
caused damage to his police cell and was subsequently charged with criminal
damage.
25. On 11 March, the COM completed paperwork to recall Mr Graham to prison for 14
days. Mr Graham appeared in court later that day and received a six-month
conditional discharge for criminal damage. (This meant that if he did not commit
another offence within that period, no further sanction would be applied in relation to
the original offence.) The recall was not approved until later that day, so Mr Graham
was not recalled directly from court.
HMP Durham, 18 March – 31 March
26. On 18 March, Mr Graham was taken to HMP Durham following his recall. During his
initial reception screening, he tested positive for cocaine. Mr Graham declined a
referral to substance misuse services. He did not raise any concerns or issues. He
told a nurse that he had Attention Deficit Hyperactivity Disorder (ADHD – symptoms
include impulsivity, hyperactivity, inattention and emotional dysregulation) and
Autism Spectrum Disorder (ASD – a developmental condition that can affect
communication, social interaction, and behaviour). He declined a mental health
referral due to only being in prison for a short time.
27. On 18 March, Mr Graham told the reception nurse that he expected to be released
homeless. The nurse recorded a plan for him to present at the local council for
housing support and to engage with the community drug and alcohol service to
ensure continuity of care.
28. During a wellbeing check, Mr Graham told staff he had concerns about probation
arrangements. He explained that he had previously been given appointments he
was unable to attend due to restrictions. On previous recalls, he said these
restrictions were linked to his risk of reoffending and his wish to be relocated to a
different area where he did not have a local connection. Mr Graham anticipated
being released homeless and said he wanted to engage with the resettlement team
and the Drug and Alcohol Recovery Team (DART). He denied any current thoughts
of self-harm or suicide.
29. On 19 March, Mr Graham was placed on a waiting list for an assessment with the
DART and referred to the community substance misuse service. He saw a
healthcare worker and disclosed daily alcohol and crack cocaine use in the
community. He reported that he had not used psychoactive substances (PS) for 16
days but expressed concern about a potential relapse. He also said that he had
previously misused buprenorphine (used to treat opioid misuse). The healthcare
worker discussed the risks of using PS, risks of overdose, reduced tolerance to
drugs and explained the effects of withdrawal.
30. On the same day, Mr Graham saw Officer A, a key worker. (Keyworkers provide
prisoners with an allocated officer that they can meet regularly to discuss how they
are and any day-to-day issues they would like to address.) Mr Graham told Officer
A that he was familiar with the prison regime and did not raise any concerns.
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31. On 20 March, Mr Graham was allocated to Ms A, recovery coordinator. On 24
March, Mr Graham told Ms B, resettlement worker, that he needed support
obtaining a bank account and benefits.
32. The following day, Ms C was allocated to complete the Basic Custody Screening
Tool (BCST). As part of this process, she emailed the COM to offer support with
housing referrals if required. Further resettlement support was expected to be
provided following Mr Graham’s release.
33. On 27 March, Mr Graham saw Ms A to prepare for his release. She informed him
about his reduced tolerance to drugs, risk of overdose and provided harm reduction
advice. He said that he would accept naloxone on release.
34. On 31 March, Mr Graham was released from prison.
Pre-release planning
35. On 5 February, the COM completed a Duty to Refer to Sunderland Council for
housing as this was Mr Graham’s local connection. (Duty to Refer means that when
prisoners need a place to live after being released, prison or probation staff must
refer them to the appropriate services or housing authorities to ensure they have
support in finding stable accommodation.)
36. On 12 March, the COM told the Duty to Refer Officer at Sunderland Council that Mr
Graham had been recalled to custody and to request housing support in preparation
for his release. Later that day, he received confirmation that Sunderland Council
would undertake a homelessness assessment.
37. On 19 March, Mr Graham was allocated to Prison Offender Manager (POM) A
However, due to POM A’s rest days and annual leave, he did not contact Mr
Graham during his time in prison.
38. On 20 March, the COM telephoned the Duty to Refer Officer to request an update.
They said that the Duty to Refer process remained open and that Mr Graham
should present himself at Sunderland Council upon release to complete the
assessment.
39. On 24 March, the COM sent instructions to the prison outlining Mr Graham’s
probation reporting requirements and additional licence conditions ahead of his
release.
40. On 27 March, Mr Graham attended a pre-release planning session with Ms A. He
told her that he had overdosed on PS approximately two weeks earlier. She noted
that he had no current signs of intoxication or withdrawal. Ms A referred him to
Reconnect, a service that helps prisoners continue accessing healthcare in the
community. She noted that Mr Graham had received naloxone training and was
motivated to abstain from drug use. She noted that no further appointments would
take place due to his upcoming release.
41. Mr Graham told Ms A that he would be homeless upon release. She advised him to
present at his local council and engage with the community drug and alcohol
service for continuity of care. Ms A told him that he had an appointment with
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Gateshead Drug Recovery partnership (GRP) scheduled for 1 April at 1.00pm. He
confirmed he would attend.
42. Mr Graham was instructed to attend Gateshead Probation Office on the day of his
release. He was aware of his licence conditions.
Post-release management
43. On 31 March, Mr Graham was released from Durham. A healthcare worker noted
that, although Mr Graham had said he would accept a naloxone kit, there was no
record of it being issued in the medical notes. Staff contacted Gateshead Recovery
Partnership (GRP) to inform them and requested that they offer him naloxone at his
appointment the following day.
44. At 12.00pm, Mr Graham attended Gateshead Probation Office as agreed to support
his engagement with appointments. He expressed concern that he might not
receive his benefit payments, as he had previously been arrested at a job centre.
Mr Graham confirmed he was aware of his appointment with Gateshead Recovery
Partnership scheduled for the following day. His next probation appointment was on
7 April at 2.00pm.
45. On 1 April, Mr Graham did not attend his scheduled appointment with Gateshead
Recovery Partnership. That morning, he attended Reconnect and registered to
engage with the service. A drug recovery worker recorded in the medical notes that
Mr Graham showed no signs of intoxication and did not disclose any illicit drug use.
Staff gave him a mobile phone and a naloxone kit, along with training on its use.
46. On 3 April, Mr Graham’s The COM attempted to contact him twice by phone after
hearing rumours that he had died from another person on probation.
Circumstances of Mr Graham’s death
47. On 3 April at approximately 11.41am, a member of the public called emergency
services after finding Mr Graham unresponsive in a car park in Gateshead.
Paramedics attended and found Mr Graham lying on his back in a sleeping bag. He
was cold to the touch, not breathing, and paramedics concluded that he had been
dead for some time so did not attempt resuscitation. A friend of Mr Graham who
was present, said that they had both used the same batch of synthetic cannabinoid
at approximately 10.30pm the previous evening.
Post-mortem report
48. The post-mortem report concluded that Mr Graham died from acute cardiac failure,
caused by the use of synthetic cannabinoids and cocaine.
Inquest
49. The inquest held on 20 June 2025, concluded that Mr Graham’s death was drug-
related.
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Findings
Substance misuse services
50. Mr Graham’s COM identified that his offending was linked to substance use and
included drug testing and engagement with community substance misuse services
as part of his licence conditions.
51. Prior to Mr Graham’s release, his recovery worker referred him to community
substance misuse services and arranged for him to receive naloxone training. She
also scheduled appointments with the community drug and alcohol team and
referred him to Reconnect for support following his release. We are satisfied that his
substance misuse support was appropriate.
Accommodation
52. Mr Graham’s COM previously referred Mr Graham to CAS3 accommodation, and
the referral was accepted. However, Mr Graham did not attend the accommodation
upon release in February and was subsequently recalled to prison for 14 days. This
recall impacted the time available to plan and secure alternative accommodation
before his final release on 31 March. Mr Graham’s COM completed an application
for Mr Graham to reside in an Approved Premises, but this was rejected.
53. Mr Graham’s local connection was with Sunderland, and the COM submitted a Duty
to Refer to Sunderland Council. Although Mr Graham expressed a preference to
live in Gateshead, he did not have a local connection to that area and was therefore
expected to seek housing support through Sunderland Council.
54. During his time in prison, Mr Graham stated that he intended to remain street
homeless unless he could live in Gateshead. To support Mr Graham’s engagement
with housing services, the COM included a licence condition requiring Mr Graham
to register and engage with housing and benefits services. the COM liaised with the
local council and followed up for updates. Mr Graham was expected to present at
Sunderland Council upon release, but did not do so, and therefore did not access
further housing support or a housing assessment.
55. We are satisfied that the COM made appropriate and timely referrals and took
reasonable steps to source accommodation for Mr Graham before his release.
Adrian Usher
Prisons and Probation Ombudsman November 2025
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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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