Jordan Donnell

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Independent investigation into
the death of Mr Jordan Donnell
on 7 June 2025 following his
release from HMP Holme House
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. 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.
3. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
4. Mr Jordan Donnell died from the effects of a combination of zopiclone, pregabalin,
temazepam and mirtazapine (all medications, only the last of which was prescribed
to him) on 7 June 2025, following his release from HMP Holme House on 5 June.
He was 40 years old. We offer our condolences to those who knew him.
5. Mr Donnell had a history of substance use. He remained abstinent from drugs in
prison and engaged with the non-clinical drug and alcohol team for ongoing
support. We did not identify any significant learning relating to the pre-release
planning or post-release supervision of Mr Donnell.
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The Investigation Process
6. HMPPS notified us of Mr Donnell’s death on 10 June 2025.
7. The PPO investigator obtained copies of relevant extracts from Mr Donnell’s prison
and probation records.
8. We informed HM Coroner for Durham of the investigation. He gave us the results of
the post-mortem examination. We have sent the Coroner a copy of this report.
9. The Ombudsman’s office contacted Mr Donnell’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. She wanted to know if
Mr Donnell was released with a naloxone kit (which temporarily reverses the effects
of an opioid overdose) and if he was given access to drug and alcohol support
services on release and asked for a copy of our report. We have addressed these
questions in our report.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Donnell’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Holme House
12. HMP Holme House is a category C training and resettlement prison which holds
convicted male prisoners. It is managed by HMPPS.
Probation Service
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
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
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Key Events
Background
14. On 7 May 2024, Mr Jordan Donnell was charged with harassment and breach of a
restraining order. He was sent to HMP Durham. On 30 October, Mr Donnell was
sentenced to 58 weeks in prison.
15. On 14 November, Mr Donnell was released on licence from Durham.
16. On 15 January 2025, Mr Donnell was recalled to prison for breach of his licence
conditions. He was sent to HMP Holme House. He was due to be released in June.
17. During his initial reception screen, Mr Donnell said he had used diazepam (used for
anxiety, insomnia, muscle spasms and alcohol withdrawal) and temazepam (used
for insomnia and sedation) in the community, obtained illicitly. His urine tested
positive for benzodiazepines. Mr Donnell was prescribed mirtazapine
(antidepressant) in prison.
18. Mr Donnell was not prescribed any opiate substitute therapy (OST) medication
because he did not have a history of opiate use. Therefore, he was not eligible for a
naloxone kit upon release under Holme House’s local policy.
Pre-release planning
19. On 16 January, Ms A, a recovery coordinator with the Drug and Alcohol Recovery
Team (DART) met with Mr Donnell as part of his induction. She gave him an
overview of support available including psychosocial interventions. Mr Donnell said
he would like to engage with these services.
20. On 17 January, Nurse A examined Mr Donnell in his cell because prison officers
were concerned he was under the influence of drugs. Mr Donnell appeared
confused and disoriented. He refused to provide a urine sample, so healthcare staff
withheld his mirtazapine for that evening. Prison officers were advised to monitor
him during the evening and alert healthcare staff if they were concerned. There is
no evidence that anyone spoke to Mr Donnell about the risk of using illicit
substances following this incident.
21. On 20 January, Ms A saw Mr Donnell for his initial assessment. He said he had a
history of using diazepam, cocaine and alcohol, but said he wanted support to
remain drug-free in the community. He said that he sometimes used buprenorphine
(an opiate substitute medication) in prison but that he had not used any since his
return and did not plan to do so. They agreed he would engage with one-to-one
structured sessions.
22. Between February and May, Ms A held four structured interventions with Mr
Donnell. He said his main issue was alcohol use which led to cocaine and other
substance use. They also identified that being unable to see his son or being
around negative peers were triggers for Mr Donnell, so they discussed a range of
coping mechanisms.
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23. On 14 May, a pre-release Board meeting took place between probation staff, prison
staff and the pre-release team at Holme House, and they discussed Mr Donnell’s
release plans. Mr Donnell had his own accommodation to return to, and
arrangements had been made for him to access community support from the local
drug and alcohol service.
24. On 4 June, Ms A completed her last structured one-to-one session with Mr Donnell
before his release the following day. She gave Mr Donnell details of his initial
appointment at County Durham Drug and Alcohol Recovery Services, which was at
10am on 9 June. Mr Donnell said that he would attend the appointment to access
support on release. Ms A gave harm minimisation advice, and they discussed the
risk of overdose due to lower tolerance after being in prison. Mr Donnell told Ms A
that he had no intentions of using illicit substances on release, and he
acknowledged the importance of surrounding himself with people who would not
encourage him to use illicit substances. He said his mum and son were positive
influences for him.
Post-release management
25. Mr Donnell was eligible to be managed under Probation Reset (a new policy
introduced in July 2024 to help alleviate workload pressures by focusing probation
practitioners’ time on individuals where the evidence shows the most impact can be
had). This meant he did not have to engage with the Probation Service as often as
he would previously have done in the community. His supervision was suspended
and he only had to attend his initial appointment on release (5 June 2025) and his
last appointment at the end of his supervision (17 November 2025).
26. On 5 June, Mr Donnell was released from Holme House.
27. Mr Donnell was released with seven days of his prescribed medication.
28. Mr Donnell was released on licence for three days and then supervised under Post
Sentence Supervision (PSS) for the rest of his sentence. He attended his initial
appointment with his community offender manager (COM) Ms B. She explained the
conditions of Probation Reset and advised him that his PSS conditions remained in
place.
Circumstances of Mr Donnell’s death
29. At around 5.45pm on 7 June, Mr Donnell’s son found him unresponsive at his home
address. He called an ambulance and started CPR.
30. At 6.04pm, paramedics arrived and took over Mr Donnell’s care. They administered
naloxone and adrenaline, but they pronounced life extinct at 6.34pm.
31. Mr Donnell’s son gave the paramedics half-empty packets of pregabalin tablets
(medication not prescribed to Mr Donnell). He said that he had seen his father
earlier that day and he was snoring. He said that he assumed Mr Donnell had taken
two pregabalin tablets as this was normal behaviour for him. No other drug
paraphernalia was found at the property.
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Post-mortem report
32. The post-mortem report concluded that Mr Donnell died from the effects of a
combination of zopiclone, pregabalin, temazepam, and mirtazapine.
Inquest
33. At the inquest held on 9 February 2026, the coroner concluded Mr Donnell’s death
was drug related.
Findings
Substance misuse
34. Mr Donnell had a long history of alcohol and substance use, and he had previously
engaged with the drug and alcohol services in prison and in the community.
35. Mr Donnell engaged well with the non-clinical DART at Holme House. He was not
managed under the clinical DART team because he did not have a history of opiate
use and therefore was not prescribed any opiate substitute medication.
36. Due to Mr Donnell being subject to Probation Reset and PSS he was not eligible for
any referrals through the Commissioned Rehabilitation Services (CRS – which aim
to provide tailored support to individuals to reduce reoffending), however the prison
DART team referred him to County Durham Drug and Alcohol Recovery Services.
They provided him with an initial appointment following his release so he could
access ongoing support in the community, but he died before he could attend his
initial appointment.
37. We consider that Mr Donnell received appropriate support with his substance use
and was aware of the dangers.
Adrian Usher
Prisons and Probation Ombudsman March 2026
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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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