Joseph Gornall

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Joseph Gornall
on 3 July 2022,
following his release from
HMP Humber
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, 2024
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 Joseph Gornall died from the toxic effects of a range of drugs on 3 July 2022,
following his release from HMP Humber on 1 July. He was 31 years old. I offer my
condolences to those who knew him.
5. We did not find any issues of concern. We make no recommendations.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
6. HMPPS notified us of Mr Gornall’s death on 8 July 2022.
7. The PPO investigator obtained copies of relevant extracts from Mr Gornall’s prison
and probation records.
8. We informed HM Coroner for Hull 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 family liaison officer contacted Mr Gornall’s mother to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond to our letter.
10. We shared our initial report with HMPPS. They found no factual inaccuracies.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Humber
11. HMP Humber is a Category C prison in Yorkshire that holds approximately 1,000
men. It was created in 2014 by the merger of two previously separate prisons, HMP
Wolds and HMP Everthorpe. Spectrum Community Health C.I.C. provides
healthcare services.
Probation Service
12. 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 supervises people
throughout their licence period and post-sentence supervision.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
13. On 5 April 2022, Mr Joseph Gornall was sentenced to 25 weeks in prison for
multiple thefts. On 14 April, he was moved to HMP Humber.
14. Mr Gornall had a history of substance misuse including heroin and crack cocaine.
He was put on a methadone (opiate substitute) programme when he arrived in
prison but a week later, he said that he wanted to come off methadone. He agreed
to continue to engage with the Drug and Alcohol Recovery Team (DART) for
psychosocial support. They advised him of his reduced tolerance and risk of
overdose.
Pre-release planning
15. Mr Gornall was homeless when he was sent to prison. On 13 June, Mr Gornall’s
community offender manager (COM) submitted a referral to Commissioned
Rehabilitative Services (CRS – probation system used to request support from
external partnerships) to assist with Mr Gornall’s housing needs.
16. On 22 June, a DART worker saw Mr Gornall. The DART worker recorded that Mr
Gornall felt good about his upcoming release and that he said he did not need a
referral to a community drug recovery service.
17. On 27 June, Mears, a temporary accommodation provider, agreed to house Mr
Gornall for 12 weeks. Mr Gornall’s COM informed Mr Gornall’s prison offender
manager on 29 June, who passed this onto Mr Gornall the same day.
18. On 1 July, the day of his release, a nurse saw Mr Gornall. She recorded that Mr
Gornall was not provided with naloxone (a medication that can rapidly reverse
opioid overdose). It is unclear from the notes whether Mr Gornall was not offered
naloxone, or if Mr Gornall declined it.
Post-release
19. On 1 July, Mr Gornall reported to Scunthorpe Probation Office, where he had a
supervision appointment with his COM. She went through Mr Gornall’s licence
conditions with him and helped him complete the necessary paperwork for his
accommodation.
20. Mr Gornall told his COM that he was not using drugs and had no intention of doing
so in the future. The COM reminded Mr Gornall of his reduced tolerance and that if
he did start using drugs again, he would have to engage with a drug rehabilitation
service, as set out in his licence.
21. Mr Gornall’s mother collected Mr Gornall from the probation office and took him to
his accommodation.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Circumstances of Mr Gornall’s death
22. On 2 July, Mr Gornall stayed at a friend’s house. When his friend came downstairs
on the morning of 3 July, he found Mr Gornall unresponsive on the living room floor,
and called the emergency services. Paramedics attended and at 8.13am, declared
that Mr Gornall had died.
23. Humberside Police informed Mr Gornall’s family and the Probation Service that Mr
Gornall had died.
Post-mortem report
24. The post-mortem report concluded that Mr Gornall died from cardiorespiratory
depression caused by the combined effects of a cocktail of drugs including cocaine.
Findings
25. Mr Gornall’s COM did the necessary accommodation referrals and accommodation
was arranged for Mr Gornall’s release.
26. Mr Gornall had a long history of substance misuse and was under the care of DART
at Humber. There is no record that he was offered reduced tolerance or harm
reduction advice at his release planning appointment, although this had been
discussed when he first arrived at Humber. In addition, he was not provided with
naloxone before his release. It is unclear from the medical record whether he was
offered naloxone but declined, or whether he was not offered it. We do not make a
recommendation, but the Head of Healthcare should consider how record keeping
could be improved.
Adrian Usher
Prisons and Probation Ombudsman August 2023
Inquest
The inquest, held on 13 May 2024, concluded that Mr Gornall died by misadventure.
Prisons and Probation Ombudsman 5
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