Jason Maynard

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Independent investigation into
the death of Mr Jason Maynard
on 25 May 2024, following his
release from HMP Swansea
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 Jason Maynard died from combined drug toxicity following his release from HMP
Swansea on 25 May 2024. He was 43 years old. We offer our condolences to those
who knew him.
5. Mr Maynard accessed satisfactory support with his substance misuse issues at
Swansea. Substance misuse support was also put in place when he was released
from prison. Staff made appropriate referrals to homelessness support services. We
did not identify any significant learning relating to the pre-release planning or post-
release supervision of Mr Maynard. We make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Jason Maynard’s death on 5 June 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr Maynard’s prison
and probation records.
8. The PPO investigator interviewed Mr Maynard’s community offender manager and
prison offender manager between 8 October and 10 October 2024.
9. We informed HM Coroner for Swansea 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 Maynard’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
asked for a copy of the report and raised concerns over their communication with
the Probation Service following Mr Maynard’s death. This has been addressed in
separate correspondence.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
12. Mr Maynard’s family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Swansea
13. HMP Swansea is a category B prison which holds convicted and remanded male
prisoners. Swansea Bay Health Board provides physical health and mental health
services. Healthcare staff are available 24 hours a day. Dyfodol provides substance
misuse services within the prison.
Probation Service
14. 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.
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Key Events
Background
15. On 16 April 2024, Mr Jason Maynard appeared in court charged with assault and
theft offences. He was remanded to prison and taken to HMP Swansea. He was
also subject to a community order (meaning he was being supervised by the
Probation Service) for theft offences.
16. At his initial health screening on 16 April, Mr Maynard told a nurse that he had a
history of substance misuse, depression and anxiety. The nurse referred him to the
mental health team. Mr Maynard was prescribed medication to lessen his
withdrawal symptoms from alcohol. He declined a referral to a specialist alcohol
treatment service. Mr Maynard was prescribed diazepam (to treat alcohol
withdrawal and anxiety) and paracetamol and continued to be monitored for signs of
alcohol withdrawal over the next few days.
17. On the same day, a GP noted that Mr Maynard had not received repeat
prescriptions for his medication since February. She prescribed promethazine
(antihistamine) and thiamine (vitamin B) to be given to him the following day.
18. On 17 April, a substance misuse support worker from Dyfodol, saw Mr Maynard. He
told her that he was detoxing from alcohol and had used heroin and other drugs in
the past. Mr Maynard was given an injection of Budival (a monthly injection of
buprenorphine used to treat dependence on opioid drugs).
19. The next day, the substance misuse support worker was allocated as Mr Maynard’s
caseworker. She completed a substance misuse assessment. Mr Maynard told her
that he used cocaine. Mr Maynard disclosed that he had previously overdosed
eighteen times but not since 2016. He also spoke about his alcohol misuse. Mr
Maynard agreed to continue working with Dyfodol in the community. Mr Maynard
was given information on the risks associated with taking drugs, including overdose.
20. On 19 April, Mr Maynard attended court. He was convicted and sentenced to 26
weeks in prison. On 22 April, Mr Maynard requested a prescription of mirtazapine
(an antidepressant). Staff added him to a waiting list to be reassessed as he had
not taken mirtazapine for over a month. (On 26 April, a GP prescribed him
mirtazapine.)
21. The following day, Mr Maynard asked to see a dentist for new dentures as he did
not have any at the time. He stated that this had affected his confidence and made
him feel depressed. He was put on a waiting list. Mr Maynard saw the substance
misuse support worker the same day who noted no concerns.
22. On 24 April, an officer was allocated as Mr Maynard’s prison offender manager
(POM). He had known Mr Maynard for several years due to previous sentences. Mr
Maynard queried whether he was eligible for early release. The POM agreed to find
out. On 3 May, Mr Maynard asked to see a dentist again. Healthcare staff sent
another request to the dentist.
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23. On 9 May, the substance misuse support worker asked Mr Maynard if he wanted to
engage in any intervention work, which he declined. Mr Maynard also saw a mental
health nurse. He said he did not know why he had been added to a waiting list to
see the mental health team. He was removed from the waiting list and encouraged
to contact healthcare if he had any concerns.
24. On 15 May, Mr Maynard was given another monthly Budival injection. On 18 May,
Mr Maynard saw his key worker. (Key workers 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 Maynard did not raise any significant issues
or concerns.
25. On 23 May, Mr Maynard was released from Swansea.
Pre-release planning
26. On 7 May, Mr Maynard saw a resettlement probation practitioner for a resettlement
interview. Mr Maynard told him that he would be homeless upon release. The
resettlement probation practitioner agreed to refer him for support with completing a
homelessness referral and complete a referral to the Department for Work and
Pensions (DWP) to assist with his benefit payments. He told the resettlement
probation practitioner that he was working with the substance misuse team and
receiving medication to support his mental health needs.
27. On 8 May, Mr Maynard’s POM emailed his community offender manager (COM),
stating that he was eligible for release under the End of Custody Supervised
Licence (ECSL) scheme. (This allowed prisoners to be released up to 70 days early
from 23 May 2024 to ease overcrowding in prisons.) Mr Maynard’s new release
date was 23 May.
28. On the same day, the COM requested additional licence conditions (including drug
testing) be added to Mr Maynard’s licence to address his substance misuse issues
and offending behaviour.
29. On 10 May, Mr Maynard’s COM spoke to the Centralised Operational Resettlement,
Referral and Evaluation hub (CORRE - a central team in probation that assist with
referrals to services and interventions) about Mr Maynard. On 15 May, a
resettlement probation practitioner gave Mr Maynard his community substance
misuse appointment for 24 May at 9.00am. CORRE completed a sentence plan on
16 May. This needed to take place before any homelessness applications could be
made for Mr Maynard.
30. On 20 May, a GP prescribed Mr Maynard a week’s worth of mirtazapine, to be
given to him on 23 May before he was released. On 21 May, Mr Maynard saw a
Forward Trust worker (substance misuse service) to complete a homelessness
referral to the local authority, which was sent on the same day. Mr Maynard’s COM
also referred him to St Giles Trust for one to one wellbeing sessions in the
community for support around resilience, coping with challenges and overcoming
barriers. A telephone appointment with them was arranged for 31 May.
32. On 22 May, a resettlement probation practitioner saw Mr Maynard to complete a
release plan. She told him that he would have a lower tolerance to drugs when
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released and discussed the risk of overdose and risks associated with combining
different drugs, as well as nitazene awareness. The resettlement probation
practitioner also told Mr Maynard how to administer naloxone (used to reverse the
effects of an opioid overdose) and advised him to take it on release. Mr Maynard
told her that he hoped to remain on his medication, sort out his benefits and
communicate more with probation and the community drug and alcohol service.
She gave Mr Maynard a copy of his community substance misuse appointment.
31. Mr Maynard was instructed to attend Swansea probation office on 23 May
immediately after his release. On 23 May, Mr Maynard was released from Swansea
with a naloxone kit.
Post-release management from HMP Swansea
32. On 23 May, Mr Maynard attended his initial probation appointment with the COM as
required at 10.00am. She noted that Mr Maynard was familiar with probation due to
his extensive offending history. Mr Maynard was aware of his licence conditions and
drug testing requirement.
33. The COM told the investigator that Mr Maynard presented well during his initial
appointment, with no evidence that he was under the influence of drugs or alcohol.
Mr Maynard told her that he was experiencing some relationship issues.
34. On the day of his release, a homelessness caseworker emailed the COM to confirm
that the local authority had placed Mr Maynard in temporary accommodation in a
hotel. Mr Maynard went to the hotel by 4.00pm. He had no confirmed move out
date.
35. Mr Maynard did not attend his initial substance misuse appointment on 24 May. He
attended on 25 May and staff recorded that he had ‘blue around his mouth’, which
raised concerns about possible drug use. He told substance misuse staff that he
was well. Due to the bank holiday, he agreed to attend another appointment on 28
May. Mr Maynard was scheduled to see the COM for his next probation
appointment on 30 May.
Circumstances of Mr Maynard’s death
36. According to the post-mortem report, on 24 May, members of the public alerted
police to Mr Maynard as he had a cut above his eye and was incoherent. Mr
Maynard would not engage with the police and refused to attend hospital. They took
him to his mother’s address.
37. That evening and throughout the next day, Mr Maynard took drugs with his friends
and consumed alcohol. He fell asleep in his friend’s car, while his friends had gone
inside their address. His friends later found Mr Maynard unresponsive in the back of
the car and called an ambulance. At 5.56pm, paramedics confirmed that Mr
Maynard had died.
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Post-mortem report
38. The post-mortem report concluded that Mr Maynard died from combined drug
toxicity. Toxicological tests identified the presence of cocaine, alprazolam
(a sedative not prescribed in the UK), bromazepam (an illicit sedative), mirtazapine,
pregabalin (used to treat epilepsy, anxiety and nerve pain), promethazine and
buprenorphine (used to treat opioid misuse) and synthetic cannabinoids.
Inquest
39. At the inquest held on 27 March 2025, the Coroner concluded that Mr Maynard’s
death was drug related.
Findings
Substance misuse support
40. Before Mr Maynard was released from Swansea, staff gave him a naloxone kit and
told him about his reduced tolerance and the dangers of overdose. He was also
given an appointment to attend community drug services. Post-release, the COM
put appropriate measures in place to address Mr Maynard’s substance misuse
issues. She included addressing his drug and alcohol issues, engaging with
community drug and alcohol services and drug testing as conditions of his licence.
41. Mr Maynard’s drug key worker told the COM that Mr Maynard attended the
community substance misuse service on 25 May, following a missed appointment.
However, he died later that day.
42. Mr Maynard received appropriate substance misuse support both pre and post
release.
Accommodation
43. Mr Maynard was appropriately referred to the local authority for accommodation
before he was released. The local authority offered Mr Maynard temporary
accommodation which he attended on the day of his release.
Adrian Usher
Prisons and Probation Ombudsman September 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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