Leanne Lytollis

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Leanne Lytollis
on 13 January 2024, following
her release from HMP New 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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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
4. Ms Leanne Lytollis died of multiple drug toxicity on 13 January 2024, following her
release from HMP New Hall on 8 January. She was 32 years old. We offer our
condolences to those who knew her.
5. We did not find any issues of concern relating to the pre and post-release planning.
We make no recommendations.
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The Investigation Process
6. HMPPS notified us of Ms Lytollis’ death on 16 January 2024.
7. The PPO investigator obtained copies of relevant extracts from Ms Lytollis’ prison
and probation records.
8. We informed HM Coroner for Northeast Lincolnshire 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 Office contacted Ms Lytollis’ family to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not have
any questions but asked for a copy of our report.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Ms Lytollis’ family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP New Hall
12. HMP New Hall is a closed prison for female prisoners aged 18 or over who have
been convicted. It is managed by HMPPS. Inclusion, Midlands Partnership NHS
Foundation Trust provide substance misuse services and. Practice Plus Group,
Health in Justice provides physical and mental health care.
Probation Service
13. 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
14. On 7 November 2023, Ms Leanne Lytollis was convicted of theft and was
sentenced to 16 weeks in prison. She was sent to HMP New Hall. Ms Lytollis was
due for release on 5 December.
15. A nurse conducted Ms Lytollis’ initial health screen. She noted that Ms Lytollis used
crack cocaine and took two pregabalin tablets every day and would drink several
alcoholic drinks. In 2020, Ms Lytollis was diagnosed with emotionally unstable
personality disorder (EUPD). She was being managed by a GP in the community.
She was prescribed sertraline (antidepressant), amitriptyline (also an
antidepressant sometimes prescribed for pain relief) and aripiprazole (anti-
psychotic). Ms Lytollis tested positive for benzodiazepine, cocaine, and
cannabinoids. The nurse referred her to the substance misuse team (SMS) and the
alcohol brief intervention service.
16. On 8 November, a member of the substance misuse team noted that Ms Lytollis
would be allocated a recovery worker for support. She started methadone therapy
and was monitored closely for alcohol and benzodiazepine withdrawal.
17. On 13 November, a recovery worker from the substance misuse team completed an
assessment with Ms Lytollis. They discussed the risks of mixing drugs, medication
and alcohol and Ms Lytollis said she was fully aware of the risks. Ms Lytollis was
also trained in the use of naloxone (a medication to reverse an opioid overdose)
and said she would take a kit with her on release. Ms Lytollis said she was
engaging with the community drug and alcohol service in the community, so the
recovery worker referred her to We Are With You (WAWY- a charity that supports
people who have challenges with drugs, alcohol or mental health).
18. On 4 December, a recovery worker of the substance misuse team gave Ms Lytollis
the details of her initial appointment with WAWY. She could attend their office any
time before 4.00pm on the day of release or at 11.00am on 6 December. There is
no evidence Ms Lytollis attended her initial appointment with WAWY.
19. On 5 December, Ms Lytollis was released from HMP New Hall on Home Detention
Curfew. (HDC - a scheme which allows some prisoners to be released early if they
have suitable accommodation.) She was released to private rented
accommodation, and she was issued with a naloxone kit.
20. On 8 December, Ms Lytollis attended an appointment with her Community Offender
Manager (COM). Ms Lytollis appeared to be intoxicated and admitted that she had
drunk an alcoholic drink before the appointment, and the previous day. They
discussed how Ms Lytollis could keep herself safe and minimise the impact of her
drinking. Ms Lytollis told the COM that the previous night she visited her uncle in
hospital and that she did not get home in time for her curfew.
21. On 11 December, Ms Lytollis was recalled to prison because she breached her
HDC curfew. She was unlawfully at large (UAL is when a person fails to take all
necessary steps to return to prison after their licence has been revoked) for 10
days.
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22. On 21 December, Ms Lytollis was convicted of theft and sentenced to one day in
prison. While at court, the police arrested her for breaching her licence and she was
sent back to New Hall. The one-day sentence ran concurrently with her recall to
prison. She was due to be released on 8 January 2024.
23. A nurse completed Ms Lytollis’ initial health screen, and she tested positive for
cannabinoids, benzodiazepines and cocaine. Ms Lytollis said that she was using
£50 of crack and £30 of heroin daily, prior to being recalled. Ms Lytollis said she
was ok with being back in prison because it was better than where she was in the
community.
24. Ms Lytollis started methadone maintenance therapy and was monitored closely by
the SMS team.
Pre-release planning
25. On 22 December, a recovery worker from the substance misuse team referred Ms
Lytollis to WAWY so that she could continue to be supported in the community. Ms
Lytollis was advised about the use of naloxone, potential overdose and the impact
of mixing drugs, medication, and alcohol. The recovery worker also informed Ms
Lytollis that she did not need an appointment for WAWY, she could attend their
office on the day of release.
26. On 28 December, a member of the resettlement team at New Hall completed Ms
Lytollis’ basic custody screening. She referred Ms Lytollis to Together Women
Project (a charity who provide holistic support women with complex needs). This
referral was initially for accommodation, but when a worker from Together Women
completed Ms Lytollis’ assessment the following day, it was evident Ms Lytollis
needed support with other areas including substance misuse. The member of the
resettlement team was aware that Ms Lytollis was already receiving support from
the substance misuse team in prison. She did not refer Ms Lytollis to the community
drug and alcohol service because this had already been done.
27. On 8 January 2024, Ms Lytollis was released on licence. She was released with a
naloxone kit and enough medication to last until she was able to get an appointment
with her community GP. Ms Lytollis had secured private accommodation.
Post-release management
28. Following her release, Ms Lytollis attended her initial appointment with her COM.
They discussed her licence conditions, and the COM reminded her to attend her
first appointment with WAWY.
29. The next day, Ms Lytollis attended her initial appointment with WAWY. A recovery
worker completed her initial assessment. Ms Lytollis started methadone therapy but
asked for buprenorphine (also known as Subutex - used to treat opiate addictions)
or Espranor (another medication for opiate addictions) as soon as possible. He told
her she would need to discuss this with the non-medical prescriber. An appointment
was booked for Ms Lytollis to see the non-medical prescriber on 15 January. Ms
Lytollis did not attend this appointment.
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Circumstances of Ms Lytollis’ death
30. On 13 January, Ms Lytollis was found unresponsive in her friends’ property. When
the police arrived, the paramedics had already confirmed that she had died. The
police found empty packets of nitrazepam (a type of benzodiazepine), pregabalin,
and carbocisteine tablets (both medications not prescribed to Ms Lytollis) and a
small amount of cannabis. The police did not suspect any third-party involvement.
Post-mortem report
31. The post-mortem report concluded that Ms Lytollis died of multiple drug toxicity.
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Findings
Substance misuse services
32. Ms Lytollis had a history of substance misuse. While she was in prison, she was
promptly referred to the SMS team, who monitored her closely, placed her on a
detoxification therapy and warned her about the risks and dangers of taking drugs.
The SMS team in prison ensured they referred her to community drug services and
community organisations to support women with a range of needs and
vulnerabilities, ensuring she would still get the necessary support once she was
released. Ms Lytollis was also trained in the use of naloxone and was released with
a supply of this. We are satisfied that both the prison and probation services did all
they could to manage the risks associated with her substance misuse.
Adrian Usher
Prisons and Probation Ombudsman September 2024
At the inquest held on 25 October 2024, the coroner conclude Ms Lytollis’ cause of death
was drug related.
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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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