Jonathan Leask

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Jonathan Leask
on 28 October 2023, following
his release from HMP
Winchester
A report by the Prisons and Probation Ombudsman
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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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 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 Jonathan Leask died by self-strangulation on 28 October 2023, following his
release from HMP Winchester on 19 October. He was 53 years old. We offer our
condolences to those who knew him.
5. We are satisfied that Mr Leask’s risk of harm was adequately assessed by prison
and probation staff and that he gave no indication that he was suicidal. We are
satisfied that Mr Leask’s death could not have been foreseen by those working with
him in the short time that he was in prison and on probation.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Leask’s death on 6 November 2023.
8. The PPO investigator obtained copies of relevant extracts from Mr Leask’s prison
and probation records.
9. We informed HM Coroner for Hampshire of the investigation. They 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 Leask’s next of kin, his wife,
to explain the investigation and to ask she had any matters she wanted us to
consider. She asked if Mr Leask was given substance misuse support and mental
health support while in prison and after his release. This has been addressed in the
report.
11. Mr Leask’s next of kin received a copy of the draft report. They pointed out some
factual inaccuracies and this report has been amended accordingly. Mr Leask’s
next of kin also raised a number of questions that do not impact on the factual
accuracy of this report and have been addressed through separate
correspondence.
12. 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 Winchester
13. HMP Winchester is a category B reception prison which holds up to 564 men who
have either been convicted or are on remand. It is managed by His Majesty’s Prison
and Probation Service (HMPPS).
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 and
have 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.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Winchester was in February 2022. Inspectors
reported that over half of all prisoners were unsentenced and nearly 90% had been
at Winchester for three months or less. The prison and health care staffing
challenges were having a detrimental impact on the delivery of mental health and
pharmacy services. This resulted in delays for mental health assessment and
delays in treatment.
16. On average, a total of 80 prisoners were released from the establishment each
month. Leaders did not collate and review data on prisoner outcomes, such as
sustainable accommodation and work on release. Inspectors saw evidence of good
work to support prisoners approaching release, although details were often not
settled until their last few days in the prison.
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Key Events
17. On 28 September 2023, Mr Jonathan Leask was remanded to HMP Winchester,
charged with harassment (committed against his wife).
Pre-release planning
18. When he arrived at Winchester, Mr Leask told the reception nurse that he did not
have any thoughts of suicide or self-harm. He said that he had never tried to harm
himself, had had no previous involvement with mental health services, and had
never received medication for his mental health. The prison requested his medical
records from his community GP, which confirmed that he did not have any history of
mental health issues.
19. The nurse asked Mr Leask about his alcohol consumption. He told the nurse that he
drank alcohol two to four times a month, and that this was not in excessive
amounts. The nurse asked if he would like support from the prison’s substance
misuse service, but Mr Leask declined. The nurse told Mr Leask about the support
services at Winchester and how he could access them, should he change his mind.
Release from Winchester
20. On 19 October, Mr Leask attended court. He was convicted of harassment and
sentenced to 28 days in prison. He was released that day due to time served on
remand. As he had not yet been allocated a community offender manager (COM)
due to being sentenced the same day, he attended Aldershot Probation Office to
see the duty probation practitioner. The probation practitioner went through his
licence conditions and Mr Leask signed to say that he understood them. Mr Leask
said that he had accommodation to return to, and that he was hoping to return to
previous employment.
21. The next day, Mr Leask was allocated a COM who issued him with his next
appointment.
22. On 27 October, Mr Leask attended his planned probation appointment. During the
appointment, Mr Leask became very emotional when speaking about the
breakdown of his marriage. Mr Leask said he felt remorse for his actions and said
that he sometimes felt overwhelmed with feelings of sadness. The COM asked Mr
Leask if he would like to be referred to Catch-22, an agency that offers emotional
well-being support. Mr Leask agreed to this and said that he would like to work on
himself. Mr Leask then asked his COM if he could travel to Italy for a cycling trip
with his son. The COM told Mr Leask that he was not allowed to go overseas while
on licence. The COM noted that the appointment ended more positively, and she
issued Mr Leask with his next appointment. After the appointment, the COM
completed the referral to Catch-22.
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Circumstances of Mr Leask’s death
23. Mr Leask was found in a van situated in a layby in Odiham on 28 October 2023. He
was found with a rope around his neck which had snapped. The rope had been tied
to a tree and then fed through the rear of the van.
24. On 1 November, Mr Leask’s next of kin notified his COM that he had died. This was
later confirmed by the police.
Post-mortem report
25. The post-mortem report concluded that Mr Leask died of strangulation by ligature.
26. The pathologist noted the presence of alcohol and cocaine in Mr Leask’s system,
however noted that the presence of cocaine in Mr Leask’s blood was far below the
average concentration associated with fatalities.
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Findings
27. As Mr Leask had already served his prison sentence whilst on remand, he was
released straight from court on the day that he was sentenced. Due to this, he had
not been allocated a COM and no pre-release work had been completed, and he
was released with a set of standard licence conditions. As this was Mr Leask’s first
offence, once a COM was allocated, she had limited information on his mental
health history, his risk factors or his triggers. The COM began to explore these with
Mr Leask during his next appointment and through formulating his initial sentence
plan. When Mr Leask became visibly upset during the appointment, she offered him
support and referred him to an agency that could help him with his emotional
wellbeing. We consider that she responded appropriately.
28. We are satisfied that whilst in prison, Mr Leask raised no concerns regarding his
mental health and said that he did not have any thoughts of harming himself. He
had no documented history of suicidal thoughts or attempts or self-harm. When
asked, Mr Leask said that he did not want any help regarding his alcohol
consumption, which he described as moderate and not problematic, from the
substance misuse service.
29. We are satisfied that Mr Leask’s risk of harm was adequately assessed by prison
and probation staff and that he gave no indication that he posed a significant risk to
himself. We are satisfied that Mr Leask’s death could not have been foreseen by
those working with him in the short time that he was in prison and under probation
supervision.
Adrian Usher
Prisons and Probation Ombudsman April 2024
Inquest
The inquest, held on 25 June 2024, concluded that Mr Leask died by suicide.
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