Katy Ross

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Independent investigation into
the death of Ms Katy Ross,
on 22 July 2023, following her
release from HMP Foston Hall
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, 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
then our recommendations should be focused, evidenced and viable. This is
especially the case if there is evidence of systemic process failures.
4. Ms Katy Ross died of acute toxic effects of cocaine on 22 July 2023, following her
release from HMP Foston Hall on 21 July. She was 40 years old. We offer our
condolences to those who knew her.
5. Ms Ross had several complex needs that made pre-release planning difficult. She
had previously been evicted from council accommodation for anti-social behaviour
and this, together with her physical and mental health needs, meant that finding
release accommodation was particularly challenging and led to Ms Ross being
released homeless.
6. Ms Ross had a history of substance misuse in the community. While she engaged
with substance misuse services at Foston Hall, she was clear that she would not
engage with community services on release.
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The Investigation Process
7. We were informed of Ms Ross’ death on 15 August 2023.
8. The PPO investigator obtained copies of relevant extracts from Ms Ross’ prison and
probation records.
9. We informed HM Coroner for Nottinghamshire 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 Ms Ross’ next of kin to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found one factual inaccuracy, which has been amended in this report.
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Background Information
HMP Foston Hall
12. HMP Foston Hall is a closed women’s prison serving courts in the Midlands. It holds
284 prisoners, including young adult women under the age of 21, unconvicted and
unsentenced women, and sentenced women (including some serving life
sentences).
13. Practice Plus Group (formerly known as Care UK) provides primary and mental
healthcare services. There are daily GP sessions from Monday to Friday, with out of
hours provision for other times. Three primary nurses and a healthcare assistant are
on duty during the day, reducing to one nurse and healthcare assistant at night.
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.
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Key Events
15. On 5 October 2022, Ms Katy Ross was remanded to HMP Foston Hall for breach of
licence conditions. She had been to prison before. Ms Ross told healthcare staff
that she was diagnosed with psychosis and schizophrenia and had previously been
admitted to a psychiatric hospital. During her time in prison, she worked with the
mental health team. Prison staff also monitored her under suicide and self-harm
prevention procedures (known as ACCT) on three occasions. Ms Ross was a
wheelchair user, having previously had a leg amputated.
16. On 9 and 13 February 2023, probation staff met to discuss Ms Ross. They recorded
that Ms Ross had been evicted from council accommodation prior to their
involvement with her, following a very high level of anti-social behaviour. Ms Ross
was due to be released homeless. Probation staff escalated this prior to Ms Ross’
release given the concerns that she would be homeless with a significant disability.
This resulted in her local council offering temporary accommodation (a hotel) for Ms
Ross on release.
17. On 15 February 2023, Ms Ross was released from prison on licence.
18. Probation staff recorded that Ms Ross did not attend the council offices, which she
needed to do to obtain the hotel accommodation (there is no evidence that she
subsequently accessed the hotel accommodation). They contacted Change, Grow
Live (CGL – a charity that works with challenging service users with complex needs,
including those with entrenched drug habits and offending behaviour) to advise
them of Ms Ross’ circumstances. Over the following week, Ms Ross’ non-
engagement continued, and probation staff decided to recall her to prison.
19. On 23 February, Ms Ross was recalled to Foston Hall for failure to comply with her
licence conditions while in the community.
20. On 3 March, Ms Ross told prison staff that she would take her life as she was
worried about her release plans. Prison staff started ACCT procedures, which they
closed on her release. Probation staff were also told that she had been managed
under ACCT procedures.
21. On 7 March, Ms Ross was released from prison homeless. Probation staff said she
was not offered hotel accommodation this time, as her local council had
relinquished its duty of care. (There is no record of why the council took this
decision, but it is likely related to Ms Ross’ complex history including her previous
evictions and non-compliance.)
22. In May, Ms Ross was admitted to hospital due to an overdose. Probation staff
recorded that Ms Ross was at risk of death by misadventure/miscalculation and that
future harm to herself could not be ruled out while her complex and difficult personal
circumstances were ongoing. Ms Ross agreed that if her social situation improved
then she would feel better. It was reported that Ms Ross might benefit from ongoing
support from the local mental health team. However, she did not meet the criteria
for a crisis resolution and home treatment teams (CRHT) referral. (CHRT provide
support to those experiencing a mental health crisis outside hospital.)
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23. On 26 June, Ms Ross was remanded to Foston Hall on charges of common assault
and theft. Ms Ross told staff at the reception health screen that she had been
released homeless from her previous prison sentence and had been living on the
streets since her release. She said that she had not been able to cope and had
reoffended. Ms Ross took a urine test, which was positive for cocaine and cannabis.
She reported withdrawal symptoms and was prescribed medication to manage this.
Healthcare staff referred her to the substance misuse service and gave Ms Ross
information about the support available to her in prison.
24. Healthcare staff also identified that previous entries in Ms Ross’ medical record
indicated schizophrenia, personality disorder and psychosis and that she had
previously been admitted to a psychiatric hospital. Ms Ross said that her mental
health was currently “okay”. Healthcare staff referred her to the mental health team.
Ms Ross continued to be supported by the substance misuse team and mental
health team while she was in prison.
25. On 29 June, Ms Ross was sentenced to eight weeks in prison for theft, common
assault, and breach of a criminal behaviour order. Ms Ross told healthcare staff that
she had recently been feeling very anxious and frustrated.
26. On 30 June, healthcare staff completed a medication reconciliation and prescribed
Ms Ross medications to manage her mental health, including antipsychotics and an
antidepressant.
27. Also in June, the Community Offender Manager (COM) made a referral for Ms Ross
to Reconnect (which offers support for up to six months post-release to assist with
engagement into appropriate health or care services) to assist in managing Ms
Ross’ mental health following her release.
28. On 4 July, Ms Ross told an allocated caseworker from the prison resettlement team,
that she would be homeless on release from custody. The prison records show that
the COM was alerted to this. The COM referred Ms Ross to Commissioned
Rehabilitative Services (CRS - partnership with the Probation Service to support
and enable successful rehabilitation) for accommodation. Ms Ross also consented
to a Duty To Refer, which probation staff submitted on 7 July. (Under the
Homelessness Reduction Act 2017, public authorities have a duty to refer service
users whom they believe to be homeless or threatened with homelessness to the
local authority.)
29. The COM prepared a plan for Ms Ross to engage with accommodation services
and determined the suitability of any address for her. Prison staff told Ms Ross that
the Department for Work and Pensions (DWP) would liaise with her regarding
making a claim for benefits prior to her release.
30. Ms Ross told prison staff that she had her grandmother and children to support her
in the community. She said that she was not motivated to work or start training on
release. Although she would not have any employment on release, Ms Ross
declined support from the ETE (Probation Service's Education, Training and
Employment programme) team.
31. Prison staff ensured that Ms Ross was aware that, on release, she would be
required to adhere to her licence conditions in respect of engaging with a drug
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worker. They also informed Ms Ross that there had been a number of drug related
deaths in the community and advised her of the increased risk of overdose within
one month of release.
32. On 4 July, Ms Ross told her caseworker that she was using heroin and crack
cocaine prior to custody. She said that she did not intend to work with the
community drug and alcohol services on release.
33. Prior to Ms Ross’ release, the COM, a member of Nottingham Women’s Centre
support worker, and a senior prison officer in Foston Hall worked to seek safe
accommodation for Ms Ross and help overcome the difficulties she experienced
finding suitable accommodation in light of her physical and mental health and
previous evictions. They sought advice from Ashfield District Council’s rough
sleeper initiative manager, and a Severe and Multiple Disadvantage Practitioner at
Saving Futures.
34. On 21 July, Ms Ross was released from Foston Hall. Accommodation had not been
secured for her at this time and she was homeless on release. She had also chosen
to refuse a discharge prescription and was therefore released from prison with no
medication. Both Foston Hall’s substance misuse team and the COM identified the
risks of this refusal to Ms Ross.
Post Release
35. On the day of her release, probation staff arranged a housing assessment for Ms
Ross at Hope for Homeless (a charity that helps people experiencing homelessness
to find suitable accommodation). Due to a mix up with the taxi that was booked for
her, Ms Ross was unable to attend the appointment. She visited their office later
that day, but they were unable to identify any housing.
36. The COM asked that Ashfield District Council offer Ms Ross an interim duty of care.
Ms Ross attended the assessment with the council. She said Ms Ross was declined
at the assessment due to concerns about her previous behaviour as a tenant and
that this might repeat. Ms Ross also said at the assessment that she had been
discharged without her antidepressant medication and had not worked with the
mental health team in the community. (The COM said that Ms Ross had not
mentioned this to her or a colleague while they had been working with her earlier
that day.)
37. The COM said that Ms Ross told her that “she would score if she failed her
assessment”.
Circumstances of Ms Ross’ death
38. On 22 July, Ms Ross was found deceased in a hotel room where drug
paraphernalia was also found. Probation staff told us that they did not know who
paid for the hotel where Ms Ross died.
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Post-mortem report
39. The post-mortem report concluded that Ms Ross died of acute toxic effects of
cocaine with alcoholic liver cirrhosis a contributory factor.
Support for staff
40. The COM told us she had received good support after learning of Ms Ross’ death.
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Findings
41. Ms Ross had several complex needs and struggled to engage with support services
both in prison and the community. She was often reluctant to take help offered,
such as with training or employment on release, and chose not to accept discharge
medication. We found evidence that prison and probation staff, in collaboration with
community support staff, made consistent efforts to understand her needs and how
to address them, and encouraged Ms Ross to engage with the help she was
offered.
42. In particular, Ms Ross had a history of substance misuse. While she engaged with
substance misuse services in prison, she said that, on release, she did not intend to
work with the community drug and alcohol services. Prison staff informed her of the
dangers of accidental overdose in the time immediately after release and discussed
recent drug related deaths in the community with her. We are satisfied that prison
and probation services did all they could to manage the risks associated with
substance misuse.
43. Ms Ross was released homeless. She had previously been evicted from council
accommodation following a very high level of anti-social behaviour. This, together
with other factors including her physical health needs and complex lifestyle, meant
that identifying release accommodation was very difficult.
44. Homelessness on release from prison is a significant and complex challenge. If an
individual is homeless, it can increase the likelihood that they will commit further
crimes or seek shelter and support in harmful places. Ms Ross’ physical and mental
health needs meant that she was particularly vulnerable, and that homelessness
would have a significant impact on her. It is clear that prison and probation staff
were alert to the very real risk that Ms Ross could die on release and appropriately
completed accommodation referrals to local authorities and homelessness charities.
Inquest
45. The inquest into Ms Ross’ death concluded on the 27 June 2024. The coroner
confirmed that Ms Ross’ death was drug related.
Adrian Usher September 2024
Prisons and Probation Ombudsman
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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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