Khaled Hassan

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Independent investigation into
the death of Mr Khaled Hassan,
a prisoner at HMP
Northumberland, on 3 October
2024
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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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.
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.
Mr Khaled Hassan died from the effects of inhaling synthetic cannabinoids (known as
spice) in his cell at HMP Northumberland, on 3 October 2024. He was 49 years old. I offer
my condolences to Mr Hassan’s family and friends.
The clinical reviewer considered that Mr Hassan’s general health and substance misuse
care was of a good standard and equivalent to that which he could have expected to
receive in the community. There were delays in providing mental health care, due to
staffing issues which have since been addressed.
Mr Hassan declined substance misuse support but was given information about the risks
of taking illicit drugs. I am satisfied that timely and reasonable action was taken in
response to a positive mandatory drug test shortly before his death.
I am pleased to note that recent improvements in security and substance misuse
treatment, as well as increased access to employment and education, has resulted in
fewer men at Northumberland testing positive for illicit substances.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman April 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. Mr Khaled Hassan was in prison from 11 July 2017 to 11 April 2022, serving a
sentence of nine years and six months imprisonment for theft and grievous bodily
harm. He was recalled to prison on 25 April 2024, for breaching the terms of his
licence and transferred from HMP Durham to HMP Northumberland on 30 April.
2. Mr Hassan had high blood pressure and mental health conditions and was listed for
care by the mental health team.
3. Mr Hassan had a history of drug and alcohol misuse. Although he was initially open
to working with the substance misuse service at Durham, he declined offers of such
support during his induction at Northumberland and again on 30 August, following a
positive test for psychoactive substances.
4. At 5.23am on 3 October, during the early morning check of prisoners, staff found Mr
Hassan lying on the floor of his cell, unresponsive and radioed a medical
emergency. Paramedics saw obvious signs of rigor mortis (stiffening of the body
after death) and pronounced life extinct at 5.50am.
Findings
5. Northumberland has an up-to-date drug strategy, published as a live document,
with a clearly defined action plan. There are also many initiatives in place to try to
reduce drug trafficking, including photocopying and scanning mail; acquiring
additional drug detection dogs; enhanced gate security; customised training; and
greater collaboration with the police and specialist teams. The latter has been
particularly fruitful in addressing staff corruption.
6. In recent months, the level of positive mandatory drug tests (the number of
prisoners testing positive for drugs across a prison) has reduced and is now below
the national average. The prison attributes this to increased and consistent access
to work and education.
7. Mr Hassan had declined substance misuse support when he arrived at
Northumberland. He was well regarded and it was not apparent to staff that he was
using illicit drugs. Prompt and appropriate action was taken when a mandatory drug
test returned as positive, including a further offer of structured support.
8. The clinical reviewer concluded that Mr Hassan’s general health and substance
misuse care were equivalent to that which he could have expected to receive in the
community. However, due to delays incurred by a shortage of staff, his mental
healthcare did not meet the expected standards. Provision had improved since the
appointment of a mental health lead. The Head of Healthcare will wish to consider
the clinical reviewer’s recommendation about maintaining this improvement.
9. We make no recommendations.
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The Investigation Process
10. HMPPS notified us of Mr Hassan’s death on 3 October 2025.
11. The investigator issued notices to staff and prisoners at HMP Northumberland,
informing them of the investigation and asking anyone with relevant information to
contact her. No one responded.
12. The investigator obtained relevant extracts from Mr Hassan’s prison and medical
records, as well as local policies and detailed statements by prison staff. She also
considered generic information from interviews she had held two weeks before Mr
Hassan’s death (for a concurrent investigation) with the prison’s head of security
and drug strategy lead and obtained an update.
13. NHS England commissioned a clinical reviewer to review Mr Hassan’s clinical care
at the prison. He and the investigator jointly interviewed five healthcare staff via
Microsoft Teams.
14. We informed HM Coroner for Northumberland of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
15. The Ombudsman’s office wrote to Mr Hassan’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. He did not reply.
16. The initial report was shared with HM Prison and Probation Service (HMPPS). They
found no factual inaccuracies.
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Background Information
HMP Northumberland
17. HMP Northumberland is a Category C prison managed by Sodexo Justice.
Spectrum Community Health CIC provides healthcare and clinical substance
misuse services. Healthcare staff are on duty from 7.30am to 7.30pm, Monday to
Friday. A GP or Advanced Nurse Practitioner, provided by Spectrum, is available for
advice out-of-hours. Humankind delivers a substance misuse psychosocial service.
18. Rethink provides primary mental health services. Tees, Esk, and Wear Valley
Mental Health NHS Foundation Trust provides secondary mental health services.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Northumberland was in August and September
2022. Inspectors found that safety and respect had improved since their previous
inspection in 2017. The flow of intelligence was good, processed promptly and
communicated clearly.
20. Inspectors reported that several steps had been taken to reduce the demand for
and the supply of illicit substances, including improved gate security and appointing
a dedicated drug strategy manager. In spite of this, far more prisoners than at
similar prisons said it was easy to get drugs and alcohol; and similarly, a larger
proportion had developed a drug problem at the prison (14%, as opposed to 8%
elsewhere). Managers had appropriately focused on responding to intelligence on
drug and alcohol use. Inspectors noted that there was strong partnership working
between the substance misuse team and the prison, links with the police were good
and the prison was actively addressing staff corruption.
Independent Monitoring Board
21. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to December 2023, the IMB
reported that there was a regular multidisciplinary meeting to manage risks and
threats from both clinical and operational perspectives; and treatment for substance
misuse remained a priority across the prison. The prison was aware of new,
powerful drugs which could endanger prisoners’ lives.
22. The IMB mentioned the Ombudsman’s attention to the national policy on X-ray body
scanners and was content that the use of such equipment was in accordance with
the policy. They reported on other security processes and stated that, on average,
more than 40 illicit items are found each month. The Board noted that the prison
operates random and suspicion-led mandatory drug testing and considered there
was a robust approach to staff corruption risks. There had been a significant
improvement in both the strategic management and day to day running of
healthcare services.
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Previous deaths at HMP Northumberland
23. Mr Hassan was the 23rd prisoner to die at Northumberland since October 2021.
Fourteen of the previous deaths were due to natural causes, six were self-inflicted
and two were drug related. There were no significant similarities between the
circumstances of Mr Hassan’s death and those previously investigated. Up to the
end of March 2025, there have been two further deaths at Northumberland, both
from natural causes.
Psychoactive substances
24. The term psychoactive substances (PS) is a broad term that refers to a drug or
other substance that affects mental processes. Synthetic cannabinoids and
synthetic opioids (including nitazene) are substances that mimic the effects of
traditional controlled drugs such as cannabis, cocaine, heroin and amphetamines.
Synthetic cannabinoids and synthetic opioids can be difficult to detect as the
compounds used in their manufacture can vary and use of these substances
presents a serious problem across the prison estate.
25. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
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Key Events
26. Mr Khaled Hassan was remanded to HMP Durham on 11 July 2017. He was later
convicted of theft and grievous bodily harm with intent, and sentenced to nine years
and six months imprisonment. Mr Hassan moved to HMP Northumberland in July
2018.
27. Mr Hassan was released on 11 April 2022, but his licence was revoked due to
concerns about his failure to keep in touch with his offender manager, deterioration
of his mental health and suspected drug use. He was recalled to prison and taken
to Durham on 25 April 2024.
28. At a reception health screen, a nurse noted that Mr Hassan had been diagnosed
with high blood pressure and had a significant mental health history. She referred
him to the mental health team.
29. Mr Hassan also had a longstanding history of substance misuse and tested positive
for cocaine and amphetamines. Healthcare staff completed drug and alcohol
assessments in which Mr Hassan reported that he drank alcohol daily and
sometimes used crack cocaine. They created an alcohol dependence care plan and
monitored his withdrawal from alcohol. During his induction, Mr Hassan told a
support worker from the substance misuse service that he wanted to work with the
service to address his crack cocaine use. (An appointment was booked for 29 April,
but Mr Hassan was at another medical review when the support worker went to see
him, so the appointment was relisted for 30 April.)
30. On 28 April, a nurse noted that he had reviewed Mr Hassan through his cell
observation panel due to suspected intoxication, but had found no evidence of
sedation, or intoxication. (There were no other references to this incident in
personal or wing records, but Mr Hassan was undergoing alcohol detoxification at
that time and had reported withdrawal symptoms twice that day.)
Transfer to HMP Northumberland
31. On 30 April, Mr Hassan transferred to HMP Northumberland. A nurse conducted an
initial health screen, including an alcohol harm assessment and they discussed his
previous substance misuse. She referred Mr Hassan to the mental health team.
32. A substance misuse support worker completed a drug and alcohol induction. Mr
Hassan disclosed no illicit drug or alcohol use and declined support from the
substance misuse service. The support worker gave him advice on harm
minimisation, tolerance levels and the risk of overdose, as well as the risks
associated with PS. He explained the referral process if Mr Hassan wanted to
engage with the service in the future and gave him a harm reduction information
sheet.
33. On 1 May, Mr Hassan had a second-stage health assessment and a mental health
triage. He was referred for a full mental health assessment, which took place on 29
May and he was listed for secondary care with the mental health team. (On 2 July,
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a consultant psychiatrist reviewed Mr Hassan, reinstated his medication and
referred him for bereavement counselling.)
34. Mr Hassan was employed in the paints workshop. He had regular meetings with his
prison key worker (until August) and reported no problems. Staff noted examples of
positive attitude and behaviour.
35. On 29 August, a urine sample for a mandatory drug test (MDT), provided by Mr
Hassan on 22 August, was confirmed as positive for synthetic cannabinoids. Staff
placed him on report for disciplinary action and referred him to Humankind, the
substance misuse service.
36. On 30 August, a substance misuse support worker discussed the referral with Mr
Hassan. She reminded him of the risks of using illicit drugs, such as PS and gave
him a leaflet. Mr Hassan declined further support and signed a disclaimer to this
effect.
37. An adjudication hearing was held on 30 September (following previous
adjournments). The charge against Mr Hassan was proven and the penalty was 14
days stoppage of earnings and access to the prison shop, suspended for six
months.
Events of 3 October 2024
38. At 5.23am on 3 October, while conducting the morning count of prisoners, two
Operational Support Officer (OSOs) saw Mr Hassan lying on the floor, facing the
back wall of his cell, but they could not see his face. They shouted to him and
banged the cell door, but he did not respond or move.
39. One of the OSOs radioed a code blue medical emergency (which indicates that a
prisoner is unresponsive or having difficulty breathing) and staff in the
communications room requested an ambulance. A Prison Custody Officer went to
the wing immediately and all three staff went into the cell. They began chest
compressions and continued CPR, using a defibrillator, until paramedics arrived at
5.40am.
40. The paramedics saw obvious signs of rigor mortis (stiffening of the body after
death) and did not attempt resuscitation. They pronounced life extinct at 5.50am.
41. A tampered vape (often used to inhale illicit substances) was found near to Mr
Hassan’s body.
Contact with Mr Hassan’s family
42. The prison’s family liaison officer and a colleague visited Mr Hassan’s brother to
notify him of Mr Hassan’s death. The family liaison officer remained in contact to
give advice about the processes to be followed. In line with national policy, the
prison contributed to the costs of Mr Hassan’s funeral, which was held on 17
October.
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Support for prisoners and staff
43. After Mr Hassan’s death, the Director debriefed the staff involved in the emergency
response to ensure they had the opportunity to discuss any issues arising, and to
offer support. The staff care team and the prison’s managing chaplain also offered
support.
44. The managing chaplain and members of his team went to each cell on the wing to
tell prisoners individually about Mr Hassan’s death and offer support. The prison
also posted notices informing other staff and prisoners of Mr Hassan’s death and
the avenues of support.
Security information after Mr Hassan’s death
45. CCTV footage showed that during evening association on 2 October, an extremely
intoxicated prisoner left Mr Hassan’s cell, supported by Mr Hassan. He sat in the
association area and other prisoners, including Mr Hassan, appeared to watch the
effects of the substances taken. Staff were unable to identify the prisoner.
46. A security intelligence report noted sources had named a prisoner who had
allegedly supplied Mr Hassan with PS the night before his death, but this could not
be corroborated.
Post-mortem report
47. The report of the post-mortem examination concluded that the cause of Mr
Hassan’s death was cardiorespiratory arrest due to synthetic cannabinoid (Spice)
inhalation. The report noted that blood and urine samples indicated that the
substances had been inhaled immediately before his death.
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Findings
Drug Strategy at HMP Northumberland
48. Northumberland has a comprehensive drug strategy, developed collaboratively with
several agencies and published in a live document. It was most recently updated in
June 2024. It is regarded as a key priority and is aligned with the HMPPS drug
strategy, as well as the UK national strategy, “From Harm to Hope: a 10-year drugs
plan to cut crime and save lives”. The main thrust of the drug strategy is to:
• restrict the supply of drugs - by improving security, building intelligence and
targeting criminal networks which aim to bring drugs into prison; and
• reduce demand for drugs - by developing more engaging and interesting
regime opportunities, providing more constructive ways for prisoners to
spend their time and ensuring the balance of incentives encourages
prisoners to make the right choices.
49. Each element of the drug strategy has a discrete and detailed plan of specific
actions, with timescales and the person responsible for delivery. Governance is via
a monthly drug and alcohol strategy meeting, attended by internal prison
departments and external agencies.
50. The Drug Strategy Lead told the investigator that, like the national picture, there are
much higher levels of drug use at the prison than they would wish. Test results and
information from healthcare and substance misuse staff indicate that the most
prevalent drugs are PS, with little use of opiates and benzodiazepines.
51. The Head of Security said that there were many variations of spice. Some were
traded on infused paper, but intelligence also suggested that there was the capacity
for prisoners to make it themselves from component parts, such as vape juice
(which is readily available), hand sanitizer and wipes. The prison was alert to the
risk of nitazenes (synthetic opioids) and several other drugs, which were also
manufactured and widespread in the community, with different levels of potency.
They were also addressing issues around the diversion of prescribed medication,
which occurred predominantly on the vulnerable prisoner wing due the age and
health conditions of many prisoners.
Measures to reduce trafficking and the demand for drugs
52. The Drug Strategy Lead and the Head of Security gave examples of initiatives,
processes and improvements to address drug trafficking and substance misuse.
53. The prison had consistently met all its targets. Between 61 and 67 mandatory drug
tests (MDTs) are completed each month (depending on the size of the population)
in line with the prison’s contractual obligations. Outcomes at Northumberland have
improved significantly over the last few months since Mr Hassan’s death, with a
positive rate of around 19/20%, which is lower than the national average. The Head
of Security attributed this improvement to proactive practices involving security
intelligence gathering; intelligence led searching; good clinical and non-clinical drug
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and alcohol treatment interventions; as well as an increase and consistent access
to work and education. Staff also conduct targeted drug testing.
54. Prisoners’ social mail is opened and photocopied before distribution, to prevent
trafficking of drugs embedded in paper. Drug detection dogs are used for legally
privileged mail. If they indicate, the correspondence is passed through the Rapiscan
scanner and tested via a small incision in the corner of the envelope. The prison is
part of a pilot scheme in which solicitors are registered and allocated an
identification code, but it is not compulsory for solicitors to participate.
55. Managers had considered making the prison paperless but had discounted this as
they initially thought it would be difficult to manage. However, it might be revisited
following precedents in other prisons and because drug trafficking had become
more sophisticated. As an example, there had been two recent instances of book
deliveries which appeared to be from approved suppliers, packed with hundreds of
sheets of ‘Spice paper’.
56. The prison has introduced enhanced gate security, including X-ray machines; body
portals for visitors and staff to allow searches on entry; a ban on liquids in unsealed
bottles; and are considering allowing staff to bring in vapes (which is not currently
allowed). They have acquired two additional detection dogs, with an increased
presence in visits and to strengthen searching correspondence and parcels. All
items must be addressed to a named person and go through various security
processes before being delivered. A body scanner is in use for prisoners
transferring to Northumberland and after hospital visits, if intelligence suggests
there are plans to smuggle contraband.
57. Managers have also implemented new secretion and ‘under the influence’ policies.
The prison can commission its own initial training courses for new staff, which
enables them to customise the training to cover their own local practices and
processes.
58. The Head of Security felt that a key strength was the development of the
relationship with the police, including the Regional Counter Corruption and
Organised Crime Teams, to break down the ‘county lines’ links in and out of the
prison. Collaboration had led to very successful operations on staff corruption with
several arrests.
Substance misuse support for Mr Hassan
59. Security intelligence reports indicated that Mr Hassan used illicit substances during
the first year of his imprisonment, but there were no further reports of this after
2018.
60. When Mr Hassan arrived at Northumberland after his recall to prison, he was
immediately offered advice and support by the substance misuse service. Although
he had been open to working with the service at Durham, he decided not to engage
after his transfer to Northumberland. Over the following months, there was no
evidence or security intelligence information to suggest that Mr Hassan used illicit
drugs or was involved in drug trafficking.
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61. When a mandatory drug test (MDT) proved positive, Mr Hassan was promptly
referred to the substance misuse service and was seen the following day. Again, he
declined support. Staff also took disciplinary action.
62. We are satisfied that after Mr Hassan’s recall to prison staff initially saw no
evidence that he was using or dealing drugs and that prompt and appropriate action
was taken in response to the positive MDT.
Clinical findings
63. The clinical reviewer concluded that Mr Hassan’s primary health care and
substance misuse care were of a good standard, equivalent to that which he could
have expected to receive in the community. However, the mental health care Mr
Hassan received was not of the required standard or equivalent to that expected.
The weaknesses identified were a delay in completing a full mental health
assessment; and the lack of a review by the assigned nurse after the assessment
took place. This was attributed to a shortage of staff.
64. We agree that the failure to follow up the assessment is a matter of concern given
the potential links between poor mental health and substance misuse. However, the
clinical reviewer is satisfied that provision has improved since the appointment of a
mental health lead. He has made a recommendation about the need to sustain the
improvements, which the Head of Healthcare will wish to consider.
Inquest
65. At an inquest held on 3 November 2025, the coroner concluded that Mr Hassan’s
death was drug related.
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