Lance Winkle

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Lance Winkle, a
resident at Elm Bank Approved
Premises, on 5 December 2023
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, 2025
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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 Lance Winkle was found hanging in a cemetery in Bradford on 5 December 2023, after
failing to return to Elm Bank Approved Premises (AP) on 4 December. He was 53 years
old. I offer my condolences to his family and friends.
On 1 December, Mr Winkle was released on licence from HMP Wealstun and arrived at
Elm Bank AP later that morning. Staff completed Mr Winkle’s induction and he agreed to
the conditions of his licence and rules of the AP. He raised no concerns with staff, he had
no history of attempted suicide or self-harm and denied any such thoughts when asked.
At 1.10pm on 4 December, Mr Winkle signed out of Elm House, and was required to return
to the AP by 7.00pm. However, he failed to return, and staff completed an out of hours
recall and notified the police. On 5 December, West Yorkshire police found Mr Winkle’s
body.
My investigation found that there was nothing in Mr Winkle’s behaviour while he was in
prison, or after he had arrived at the approved premises to indicate that he would take his
life.
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 June 2024
Prisons and Probation Ombudsman
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
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Summary
Events
1. In May 2022, Mr Lance Winkle was charged with racially aggravated harassment
towards his neighbour and was placed on an electronic tag until his court
appearance on 10 March 2023. During the compilation of court reports, Mr Winkle
said he was anxious and worried about the prospect of losing his home and
threatened suicide if he received a custodial sentence. The comments were
recorded and flagged on his probation record.
2. On 10 March 2023, Mr Winkle was sentenced to six months in prison. However, as
he had spent 149 days on HDC, he was automatically released from court on a
four-year restraining order. He immediately breached his restraining order and was
charged with further offences and remanded to HMP Leeds.
3. On 6 April 2023, Mr Winkle was sentenced to 16 months in prison for stalking. On
15 May 2023, he was transferred to HMP Wealstun.
4. During his time in prison, Mr Winkle was never subject to suicide and self-harm
monitoring and staff did not record any concerns about his risk to himself. He knew
he had lost his home as a result of his offence, but staff did not have any concerns
about him.
5. On Friday 1 December 2023, Mr Winkle was released from HMP Wealstun on
conditional licence to reside at Elm Bank Approved Premises (AP). He received an
induction and denied any thoughts of suicide or self-harm. Over the following few
days, staff had no concerns about Mr Winkle.
6. At 1.10pm on 4 December, Mr Winkle left Elm Bank. He gave staff no cause for
concern. When Mr Winkle had not returned by the 7.00pm curfew, AP staff began
the process to recall him to prison.
7. On Tuesday 5 December, a member of Mr Winkle’s family phoned AP staff and told
them that the police had found Mr Winkle hanged in a cemetery in Bradford earlier
that day.
Findings
8. Mr Winkle had no recorded history of suicide attempts or self-harm in prison or in
the community. He had threatened suicide in 2023, during the court process, but
once in prison, staff recorded no concerns about him.
9. In the few days he was at Elm Bank AP, Mr Winkle gave staff no cause for concern.
We found no evidence that staff should have considered his risk of suicide to be
raised during the short time he was there.
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The Investigation Process
10. HMPPS notified us of Mr Winkle’s death on 6 December 2023.
11. The investigator issued notices to staff and prisoners at Elm Bank Approved
Premises informing them of the investigation and asking anyone with relevant
information to contact him. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Winkle’s prison and
probation records.
13. The investigator interviewed a Senior Probation Officer and a manager at Elm Bank
through Microsoft Teams on 26 January 2024.
14. We informed HM Coroner for West Yorkshire (Western) of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
15. The Ombudsman’s family liaison officer contacted Mr Winkle’s sister to explain the
investigation and to ask if she had any matters, she wanted us to consider. Mr
Winkle’s sister raised no questions about her brother’s care but asked for a copy of
our report.
16. A copy of the initial report was made available to Mr Winkle’s sister, but she did not
comment on our findings.
17. An inquest was concluded on 31 October 2024, and gave cause of death as suicide
by hanging.
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Background Information
Elm Bank Approved Premises
18. Approved premises (formerly known as probation and bail hostels) mostly
accommodate offenders released from prison on licence and those directed there
by the courts as a condition of bail. Their purpose is to provide a supportive and
structured environment. Residents are responsible for their own healthcare and are
expected to register with a GP.
19. Elm Bank Approved Premises is a 22-bed residence for men, providing one double
room and the rest single rooms. Elm Bank is an enhanced Approved Premises and
accommodates those who pose a higher risk to the public. Elm Bank only accepts
those who are subject to licence conditions and not those on bail. It is one of four
Approved Premises operated by the West Yorkshire Probation Area.
Previous deaths at Elm Bank Approved Premises
20. Mr Winkle was the second resident to die at Elm Bank since December 2020.The
previous death was drug related. Up to the end of February 2024, there has been
one self-inflicted death at Elm Bank since Mr Winkle’s death. There are no
similarities with findings from the previous investigations.
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Key Events
21. In May 2022, Mr Winkle was charged with racially aggravated harassment towards
his neighbour. This resulted in Mr winkle being placed on Home Detention Curfew
(HDC - an electronic tag and curfew) prior to his court hearing.
22. During a pre-sentence report interview on 14 February, Mr Winkle said that he was
anxious and worried about the prospect of losing his home and threatened suicide if
he received a custodial sentence. His comments were recorded and flagged on his
probation record.
23. On 10 March 2023, Mr Winkle was sentenced to six months in prison. However, as
he had spent 149 days on HDC he was automatically released from court on a four-
year restraining order.
24. That day, Mr Winkle returned to his home address and continued to harass his
neighbour. He breached his restraining order and received further criminal charges
and was remanded to HMP Leeds.
25. On 6 April 2023, Mr Winkle was sentenced to 16 months in prison for stalking. On
15 May 2023, he was transferred to HMP Wealstun.
26. While in prison, Mr Winkle received favourable comments about his attitude and
behaviour. He had no history of poor mental health, substance misuse or attempted
suicide or self-harm in prison or in the community and reported no thoughts of
suicide or self-harm to staff. Mr Winkle knew that he had lost his home due to his
offences, but he had not repeated any thoughts of suicide or self-harm.
Elm Bank Approved Premises
27. On Friday 1 December 2023, Mr Winkle was released on conditional licence from
HMP Wealstun to reside at Elm Bank AP.
28. Mr Winkle’s appointed probation practitioner was absent from work and his case
was allocated to another probation practitioner on the day of his release.
29. Due to Mr Winkle’s offences, his licence conditions included an imposed exclusion
zone, to ensure he stayed away from his victim, and which prevented him from
entering certain areas of Bradford. This meant Mr Winkle was unable to report to his
allocated probation office (as it was inside the exclusion zone) and arrangements
for reporting elsewhere had yet to be arranged. As such, he reported directly to Elm
Bank AP.
30. On his arrival at Elm Bank AP, a residential worker spoke to Mr Winkle and
completed the first stage induction with him. He agreed to comply with the premises
rules. He was allocated a single room.
31. Along with standard licence conditions and the exclusion zone, Mr Winkle was also
required to sign in daily at Elm Bank at 1.00pm and was required to be in the AP
between the hours of 7.00pm and 7.00am daily.
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32. On Saturday 2 December, a residential worker completed the stage 2 induction and
a Support and Safety Plan with Mr Winkle. AP staff are required to complete a
Support and Safety Plan (SaSP) to assess and manage residents who might be at
risk of suicide and self-harm. The SaSP was introduced to all Approved Premises
as part of the Collaborative Approach to Risk and Emotion (CARE) approach. All
residents who arrive at an AP receive a welfare assessment and an individual
support plan. This is completed by the residents and their keyworker within one day
of arriving at the AP.
33. Mr Winkle said he felt ‘good’ about being at Elm Bank. The residential worker asked
him to rate his mood from zero (low) to 10 (the best possible), and Mr Winkle said
he felt his mood was eight. When asked how he would deal with things over the
coming days, Mr Winkle said that he would speak with staff.
34. The residential worker asked Mr Winkle whether he had anyone he could speak
with, but Mr Winkle said that he did not need anyone. He denied any thoughts of
suicide or self-harm, and the residential worker recorded that Mr Winkle had no
history of suicide attempts or self-harm either in the community or while in prison.
35. In concluding his interview with Mr Winkle, the residential worker recorded that Mr
Winkle did not want to be in an AP and that he intended to speak with his
supervising officer the following week about moving on. He said that Mr Winkle’s
engagement throughout the interview was poor, but he made good eye contact
throughout. Mr Winkle again said that he had never had any suicide or self-harm
issues, had no substance misuse or alcohol problems and declined to be registered
with a doctor.
36. The AP manager told the investigator that, while the residential worker checked Mr
Winkle’s probation records for relevant information when completing the Support
and Safety Plan, the flag relating to his threat to take his life in 2023 would not have
triggered any further consideration in the absence of any additional concerns about
his risk to self.
37. Over the following two days, Mr Winkle left Elm Bank AP for short periods to go to
the local shop. AP staff did not report any concerns about his behaviour and Mr
Winkle raised no issues during his time at the AP.
Events between 4 and 6 December
38. During the morning on Monday 4 December, Mr Winkle remained in the AP and
signed in as required by conditions of his licence at 1.00pm. At 1.10pm, Mr Winkle
signed out of Elm Bank and indicated to staff that he planned to go to Dewsbury. He
did not appear upset or give staff any cause for concern.
39. Mr Winkle was required to return to Elm Bank by 7.00pm. When he did not do so,
staff completed the Out Of Hours recall paperwork and waited an hour to see if he
returned. When Mr Winkle had still not returned, staff contacted local hospitals and
police, and after confirming that Mr Winkle had not been admitted to hospital and
was not in police custody, staff submitted the out of hours recall application.
40. At 9.20pm on Tuesday 5 December, a residential assistant received a telephone
call from Mr Winkle’s niece. She said that Bradford police had found the body of a
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male at a cemetery in Bradford earlier that day, and they believed it to be Mr
Winkle.
41. At 9.35pm, the on-call manager advised the AP staff to contact the police to obtain
further information.
42. At 11.18pm, two police officers from West Yorkshire police attended Elm Bank and
confirmed that Mr Winkle had been found hanged at 12.30pm that day.
Contact with Mr Winkle’s family
43. On 6 December, Mr Winkle’s sister visited Elm Bank and met with the AP manager.
The manager offered her condolences and support. Mr Winkle’s property was
handed back to the family.
44. The Probation Service contributed towards funeral expenses in line with national
policy.
Support for residents and staff
45. After Mr Winkle’s death, the AP manager debriefed the AP staff to ensure they had
the opportunity to discuss any issues arising, and to offer support. She also directed
them to other workplace support services.
46. The AP manager posted notices informing other residents of Mr Winkle’s death and
offering support. She held a meeting with the residents to provide an opportunity to
talk.
Post-mortem report
47. A post-mortem gave Mr Winkle’s cause of death as hanging. Toxicology tests
indicated no illicit substances in Mr Winkle’s blood.
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Findings
Assessment of risk
48. Mr Winkle had no recorded history of suicide attempts or self-harm, mental ill-health
or substance misuse. The only reference to harming himself was during a pre-
sentence report meeting in February 2023, when he said that he was concerned
about losing his home and if was to happen, he would hang himself. The comments
were recorded in the report and noted as a ‘flag’ on his probation record and no
further action was taken.
49. At the time of the pre-sentence report, Mr Winkle was on remand at HMP Leeds
and during this period there were no concerns raised about his well-being or
potential risk to himself. Following sentencing, he was transferred to HMP
Wealstun. Throughout his time at Wealstun, staff recorded no concerns about his
behaviour or well-being. Mr Winkle was aware that he had lost his home due to his
offending, but never raised any other concerns about this.
50. When Mr Winkle arrived at Elm Bank AP on 1 December 2023, staff carried out the
induction and completed the Support and Safety Plan appropriately. Mr Winkle
denied any thoughts of suicide, or any history of suicide attempts or self-harm. Staff
did not have any concerns about him.
51. We found nothing to suggest staff at Elm Bank should have identified that Mr
Winkle’s risk of suicide had increased in the short time he was at the AP.
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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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