Kevin Hassan

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Kevin Hassan,
on 18 December 2024,
following his release from
HMP Chelmsford
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 Kevin Hassan died from cardio-respiratory failure and polysubstance toxicity on
18 December 2024 following his release from HMP Chelmsford on 11 December
2024. He was 40 years old. We offer our condolences to those who knew him.
5. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Hassan.
6. We make no recommendations.
Prisons and Probation Ombudsman 1
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The Investigation Process
7. HMPPS notified us of Mr Hassan’s death on 27 February 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Hassan’s prison
and probation records.
9. The Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
10. The Ombudsman’s office contacted Mr Hassan’s family to explain the investigation
and to ask if they had any matters, they wanted us to consider. Mr Hassan’s family
wanted to know about the treatment Mr Hassan received for his mental health
during his time in prison. They also asked a for a copy of our report. We have
answered Mr Hassan’s family’s question in this report.
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Background Information
HMP Chelmsford
11. HMP Chelmsford is a category B local reception and resettlement prison holding
adult men and a small number of young adults. It is managed by HMPPS. HCRG
provides primary care, secondary mental health, pharmacy, and other services. The
Forward Trust provides substance misuse services and Time For Teeth provides
dental services.
Probation Service
12. 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.
HM Inspectorate of Prisons
13. The most recent inspection of HMP Chelmsford was in February 2024. Inspectors
reported that staff had worked hard to reduce contraband getting into the prison.
Subsequently, violence had reduced, the positive MDT rate was lower than at
comparable prisons at 15% and higher levels of prisoner attendance at education,
training and work had been achieved, but self-harm had increased and poor
coordination between the two providers of therapeutic support and long waiting lists
prevented the delivery of much needed support for prisoners struggling with their
mental health.
Prisons and Probation Ombudsman 3
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Key Events
Background
14. On 28 August 2024, Mr Kevin Hassan was remanded to HMP Chelmsford, charged
with burglary. He had been in prison several times before.
15. Mr Hassan had a history of substance misuse (cocaine), depression and had a
mental health disorder. During his reception screen, Mr Hassan said that he had
been struggling with his drug addiction and wanted help. Mr Hassan was referred to
the substance misuse use team and the mental health team.
16. On 29 August, the substance misuse team saw Mr Hassan after he was showing
signs of withdrawal. A nurse took his clinical opiate withdrawal scale which
measured nine and indicated that he needed treatment. That day, Mr Hassan
started a methadone detoxification programme and was prescribed 10mls of
methadone. Mr Hassan said that he was prescribed 30mg of mirtazapine for
depression and 40mls of methadone in the community. Over the following weeks,
Mr Hassan’s methadone dosage gradually reduced by 5ml. As Mr Hassan was
known to suffer from anxiety and depression, this was managed under IAPT
(improving access to psychological therapies) and he was added to the waiting list
for counselling.
17. The reduction of the methadone went well and Mr Hassan did not experience any
withdrawal symptoms. The substance misuse team continued to offer support and
advice.
18. Over the following months, Mr Hassan did not report any physical or mental health
difficulties.
Release from HMP Chelmsford
19. On 11 December, Mr Hassan was preparing to attend court for sentencing. As he
was still on remand, he did not undergo any pre-release planning. A nurse and staff
from the substance misuse service saw Mr Hassan in case he did not return from
court. He was given his methadone dose of 15mls, issued with a naloxone kit, and
he was advised how to administer it and was told about the risks of drug overdose.
Mr Hassan was encouraged to engage with his local community drug team if he
was released, and was advised that if he encountered any problems, he should
inform the local drug team so that they could contact the integrated drug treatment
service at the prison, to which he agreed.
20. Later that day, Mr Hassan attended court. He was sentenced to four months
imprisonment for burglary, however as he had been held on remand for that period,
and he was released directly from court.
21. Mr Hassan reported to his local probation office for his initial appointment with the
duty community offender manager (COM). The duty COM went over his licence
conditions and his induction pack. Because Mr Hassan did not have any secured
accommodation, the duty COM told him to go to the local housing office. Mr
Hassan’s next probation appointment was scheduled for 19 December.
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Circumstances of Mr Hassan’s death
22. At 6.23am on 18 December, Redbridge council cleaners found Mr Hassan in public
toilets. They notified the police and the ambulance service, and he was confirmed
deceased on their arrival.
Post-mortem report
23. The post-mortem report concluded that Mr Hassan died from cardio-respiratory
failure and polysubstance toxicity (cocaine, street heroin and nitazene – a synthetic
opioid).
Findings
24. Mr Hassan had a history of substance misuse. While it is noted that he actively
engaged with the substance misuse service in prison, the plan was that once he
was back in the community, he would continue to engage with the local drug
support service, which would have provided him with additional support.
25. Mr Hassan was cared for and supported with his mental health at Chelmsford, was
prescribed appropriate medication, and he was referred for counselling. Mr Hassan
did not raise any concerns about his mental health during his time at Chelmsford
and no referrals were made to community services.
26. Mr Hassan was on remand awaiting sentencing, therefore there was no pre-release
provision available to him. Suitable accommodation had not been secured for Mr
Hassan because he was released directly from court. During his initial probation
appointment, the duty COM advised Mr Hassan to attend the local housing office.
We do not know whether he attended as advised.
27. We are satisfied that both the prison and probation services did all they could to
support Mr Hassan.
28. We make no recommendations.
29. The initial report was shared with HM Prison and Probation Service (HMPPS) and
Healthcare. HMPPS and HCRG care group did not find any factual inaccuracies.
30. At the inquest held on 16 January 2026, the coroner concluded that Mr Kevin
Hassan’s death was drug related.
Adrian Usher
Prisons and Probation Ombudsman October 2025
Prisons and Probation Ombudsman 5
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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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