Jason McDonagh

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Jason McDonagh,
on 4 December 2023,
following his release from
HMP Five Wells
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, 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
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. Since 6 September 2021, the PPO has been investigating 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 McDonagh died on 4 December 2023 following his release from HMP
Five Wells on 1 December 2023. He died from ketoacidosis (a condition which can
be caused by starvation and results from the body producing too many ketones). He
was 36 years old. I offer my condolences to those who knew him.
5. Mr McDonagh refused to access the support and services available to him in prison
and to prepare him for release into the community. We are satisfied that prison,
probation and healthcare staff took all reasonable steps to get Mr McDonagh to
engage both in the prison regime and to access the support and services available
to him. We therefore make no recommendations. However, it is tragic that Mr
McDonagh’s lack of engagement resulted in him being released vulnerable,
homeless, without access to community services, and ultimately resulted in his
death.
6. Homelessness on release from prison is a significant and complex challenge which
we see in a number of our investigations into post-release deaths. It is made all the
more challenging when those whom services are designed to support refuse to
engage and cannot access services they need. Partners working in this space face
an ongoing challenge to improve engagement to prevent such deaths.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
7. HMPPS notified us of Mr McDonagh’s death on 11 December 2023.
8. The PPO investigator obtained copies of relevant extracts from Mr McDonagh’s
prison and probation records.
9. We informed HM Coroner for Northamptonshire of the investigation. She gave us
the results of the post-mortem examination. We have sent the coroner a copy of this
report.
10. The Ombudsman’s family liaison officer contacted Mr McDonagh’s sister 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 the report.
11. Mr McDonagh’s family received a copy of the draft report. They did not make any
comments.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Five Wells
13. HMP Five Wells is a category C male prison in Wellingborough which opened in
2022. The prison is operated by G4S. Healthcare services are provided 24 hours a
day by Practice Plus Group.
Probation Service
14. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board. The
Probation Service has links with local partnerships to whom, where appropriate,
they refer people for resettlement services. Post-release, the Probation Service
supervise people throughout their licence period and post-sentence supervision.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
15. Mr Jason McDonagh was a registered sex offender. On 15 February 2023, he was
convicted of a failure to comply with notification requirements, and he was
sentenced to thirty months in prison.
16. Mr McDonagh was initially sent to HMP Bullingdon but was later transferred to HMP
Five Wells on 22 February.
17. When he arrived, Mr McDonagh declined to see healthcare staff for his initial health
screen. He was noted to be very unkempt and would not engage with anyone.
Subsequently, Mr McDonagh was referred to the mental health team for review.
18. On 23 February, a nurse tried to carry out a mental health review. She recorded
that Mr McDonagh would not respond verbally to her questions but instead would
nod or use hand gestures. When asked if he wanted mental health support, Mr
McDonagh shook his head.
19. Later that day, following a multidisciplinary meeting (MDT), a decision was made
that healthcare staff would carry out daily welfare checks on Mr McDonagh.
20. On 1 March, a nurse carried out a further mental health assessment. She noted that
Mr McDonagh would not speak and waved his hand to indicate that he did not want
to speak. However, he was assessed as having mental capacity to make decisions
for himself. It was noted that his capacity should be assessed on a regular basis.
21. During the following five months, the mental health team continued to monitor Mr
McDonagh and his case was discussed on multiple occasions at the MDTs.
22. On 18 July, following an MDT, it was recorded in the medical records that Mr
McDonagh was still refusing to engage with the healthcare team. A decision was
made that he would no longer be discussed on a regular basis but instead would be
discussed if any issues arose.
23. On 23 July, at a mental health review, it was recorded that Mr McDonagh
unequivocally had mental capacity to make decisions.
24. Mr McDonagh would not engage with prison officers and did not fully participate in
prison life.
Pre-release planning
25. On 31 October, a Community Offender Manager (COM) contacted a Prison
Offender Manager (POM), to find out if Mr McDonagh’s pre-release work had
started. The POM responded and advised that he had refused to engage.
26. On 22 November, the COM and POM discussed Mr McDonagh and it is recorded
that they were concerned about his lack of engagement. The COM said that in
relation to his housing needs, she wanted to refer him for a place at an approved
premises and to the local authority’s homelessness team, but she was unable to do
so without his consent. (Under the Homelessness Reduction Act 2017, public
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
authorities have a duty to refer service users whom they believe to be homeless or
threatened with homelessness to the local authority. However, this requires the
consent of the service user.)
27. Later that day, the POM tried to obtain Mr McDonagh’s consent. She recorded that
she explained to Mr McDonagh what they were trying to do but he still refused to
provide consent.
28. On 1 December, Mr McDonagh was released from HMP Five Wells. The prison
contacted the COM and told her that that Mr McDonagh had refused to participate
with the release process, and he had refused to sign his licence agreement.
Post-release
29. Mr McDonagh did not attend the probation office for his appointment with the COM,
which had been scheduled for 3.00pm on the day of release. Subsequently, she
asked for Mr McDonagh to be recalled into custody for failing to adhere to one of his
licence conditions.
Circumstances of Mr McDonagh’s death
30. On 4 December, Northamptonshire Police were contacted by a member of the
public who had found Mr McDonagh lying among some bushes in Croyland
Gardens, Wellingborough. Both the police and paramedics attended the scene and
Mr McDonagh was confirmed dead by paramedics at 9.41am.
Post-mortem report
31. The post-mortem report concluded that Mr McDonagh died of ketoacidosis. (There
is no evidence in Mr McDonagh’s medical records that he had diabetes.)
Coroner’s inquest
32. We were advised by the coroner on 12 February that they were closing their
investigation into Mr McDonagh’s death, and an inquest would not take place.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
33. We are satisfied that prison, probation and healthcare staff took all reasonable
steps to get Mr McDonagh to engage both in the prison regime and to access the
support and services available to him in prison and on release. He was considered
to have the mental capacity to refuse mental health support and there was little staff
could do except continue to encourage him to engage, which they did.
34. Due to his persistent lack of engagement and consent, Mr McDonagh’s COM could
not make referrals to the relevant agencies and as a result, Mr McDonagh was
released from prison homeless. Homelessness on release from prison is a
significant and complex challenge. This was particularly the case for Mr McDonagh
who declined all the services and support potentially available to him (from
healthcare to accommodation services) both in prison and to prepare him for
release into the community.
Adrian Usher
Prisons and Probation Ombudsman June 2024
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