Lee Gresham

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Lee Gresham
on 17 April 2023, following his
release from HMP Hull
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 detained people 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 been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
4. Mr Lee Gresham died in hospital on 17 April 2023, from the effects of cocaine use,
following his release from HMP Hull on 5 April. Mr Gresham was 40 years old. We
offer our condolences to his family and friends.
5. We found no issues of concern and make no recommendations.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
6. HMPPS notified us of Mr Gresham’s death on 21 April 2023.
7. The PPO investigator obtained copies of relevant extracts from Mr Gresham’s
prison and probation records.
8. We informed HM Coroner for North East Lincolnshire and Grimsby 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 family liaison officer contacted Mr Gresham’s mother to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not have any questions for the investigation but asked for a copy of the report.
10. The initial report was shared with Mr Gresham’s mother. She did not make any
comments.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found some factual inaccuracies relating to the identification of the roles of
individuals checking on Mr Gresham’s accommodation. These have been corrected
in this final report.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Hull
12. HMP Hull is a local inner-city prison with a complex population of remand and
sentenced prisoners. It can hold about 1,000 men, mostly in double cells. About 130
prisoners are released each month.
HM Inspectorate of Prisons
13. The most recent inspection of HMP Hull was in March 2022, which was a review of
progress following concerns raised in the previous inspection in 2021. The
inspectors found good progress in some areas, including in resettlement with better
coordination by the prison with probation staff in the community. Inspectors were
concerned that healthcare services were still failing in some critical areas. However,
the healthcare provider has changed since the inspection.
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.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
15. Mr Lee Gresham had an extensive history of acquisitive offending linked to
substance misuse. He had been in prison numerous times. He had a poor history of
complying with licence conditions, for example, by failing to attend substance
misuse service (SMS) or probation appointments. Before Mr Gresham’s latest
sentence, he was most recently admitted to HMP Hull in October 2022, and
released under licence on 20 February 2023. He was supervised in the community
by the Probation Service and the police as part of the Integrated Offender
Management programme (IOM, a programme which identifies persistent and
problematic offenders who are managed jointly by partner agencies working
together).
16. On 7 March, the Probation Service decided to recall Mr Gresham to prison. This
was due to several missed appointments and alleged further offending. The recall
dossier said that a period of imprisonment would give Mr Gresham the opportunity
to reengage with drug treatment in prison.
17. However, on 9 March, before he was recalled, Mr Gresham received a further
sentence of 56 days imprisonment for theft. He was taken to Hull on 10 March. On
arrival, Mr Gresham told healthcare staff that he did not have a problem with drugs
and did not want to engage with the prison SMS. Therefore, he was not tested for
drugs and had no input from the prison SMS while at Hull.
18. Mr Gresham was only at Hull for a short period and after receiving some medication
for his asthma at the beginning of his sentence, he had no further contact with
healthcare staff.
Pre-release planning
19. Prior to his imprisonment in March, Mr Gresham had not engaged with the
community SMS. Although his recall dossier expressed the hope that he would
have the opportunity to reengage with the prison SMS, he chose not to do so. This
meant that there were no arrangements relating to substance misuse when he left
prison. His lack of engagement also meant that on release from prison he was not
issued with naloxone (a medicine that rapidly reverses an opioid overdose), or
reminded of the increased risk of overdose because of reduced tolerance following
abstinence in prison.
20. Despite his lack of engagement with the prison SMS, Mr Gresham’s community
offender manager (COM) added drug treatment and testing conditions to his
licence. This meant that contact with a community SMS could be enforced if she
had concerns.
21. Mr Gresham refused to attend a resettlement appointment in prison on 27 March.
However, through multi-agency working, staff secured him CAS3 accommodation
on release. (CAS3 is short term accommodation with low level support which can
be made available to prisoners on release who would otherwise be at risk of being
homeless). Prior to his release, the probation office contacted the prison to inform
Mr Gresham of the details of the accommodation he would be going to.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Post-release planning
22. On 5 April, Mr Gresham was released from prison. Mr Gresham was late in getting
to Grimsby because of transport issues. Therefore, he was unable to report to
probation as, if he had done so, he would not have been able to pick up the keys to
his accommodation in time. However, Mr Gresham telephoned the probation office
and staff made him an appointment for 11 April.
23. The day after his release from prison, an IOM Police home visit was completed at
Mr Gresham’s accommodation, but he was not there.
24. On 11 April, Mr Gresham attended his appointment with the COM. She noted that
he appeared to be intoxicated and she asked about his substance misuse. Mr
Gresham said that he had been drinking alcohol but was concerned that he would
relapse into opioid misuse. His COM asked him to go to the Community SMS. Mr
Gresham agreed to do so. However, he does not appear to have gone there.
25. On 13 April, Mr Gresham’s accommodation key worker made a visit to his
accommodation but Mr Gresham was not there. However, there was evidence of
drug paraphernalia in a communal area, although it could not be definitively linked
to Mr Gresham. The key worker passed on their concerns to the COM. The COM
discussed follow up actions with her manager and they decided to test Mr Gresham
for drugs at his next appointment the following week. If he tested positive, she
would have issued a warning and then, as part of his licence conditions, directed
him to attend the community SMS.
Circumstances of Mr Gresham’s death
26. On 14 April shortly after 11.00am, paramedics attended another property after Mr
Gresham had been found unconscious. Paramedics reported that they were told
that Mr Gresham had taken a variety of drugs and he was surrounded by drug
paraphernalia. They also said that there was evidence that someone had made use
of a naloxone kit before they arrived.
27. The paramedics carried out cardiopulmonary resuscitation (CPR) and attached a
defibrillator (a device that can shock a heart back into normal rhythm in some
circumstances) to Mr Gresham. They succeeded in restoring his blood circulation
but he had to be artificially ventilated as he could not breathe unaided.
28. Paramedics took Mr Gresham to hospital. Hospital scans showed that Mr Gresham
had critical damage to his brain. He died in hospital on 17 April.
Post-mortem report
29. The post-mortem report concluded that Mr Gresham died from a haemorrhagic
stroke (bleeding in or around the brain, which causes brain cells to die), caused by
cocaine abuse. The report said it was likely that cocaine had severely increased his
blood pressure, leading to the damage to his brain. Post-mortem testing also
showed that Mr Gresham had taken diazepam and morphine (both prescription-only
medications which are also used recreationally) although these were not considered
causal to his death. These were found to be at therapeutic levels consistent with
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
prescription doses. However, neither of these drugs were prescribed to Mr
Gresham in prison or in the community immediately prior to going to prison, so it is
likely that he was using them recreationally.
Findings
30. Mr Gresham inconsistently engaged with services such as probation, IOM police
staff, and SMS providers. Mr Gresham’s recall documents said that he had told staff
that his main drug use recently had been cocaine. Although Mr Gresham said he
used it weekly, staff noted it was more frequent than this and included intravenous
heroin use. Because of his lack of engagement with services, it was unclear exactly
what Mr Gresham’s levels of substance misuse were in March 2023. However,
previously on entering prison in October 2022, he said he was spending at least
£100 a day on crack cocaine, and was also using heroin several times a day. At
that time he tested positive for drugs including cocaine.
31. When Mr Gresham returned to prison on 10 March 2023, he chose not to engage
with SMS services. He said that he did not use drugs and therefore did not undergo
a urine drug screen. Hull confirmed that this is only offered to prisoners who declare
a drug problem in order to help tailor a drug treatment programme. So, although the
recall dossier expressed the hope that Mr Gresham would have an opportunity in
prison to reengage with SMS, engagement was voluntary and Mr Gresham did not
wish to address his drugs use.
32. The SMS team leader at Hull told the investigator that when a prisoner engages
with their services, they ask for their consent to speak to their COM and prison
offender manager (POM). This is to provide a more collaborative approach
particularly around support in the community with housing and to improve prisoners’
continuity of care.
33. Although Mr Gresham had been issued with naloxone when previously released
(most recently on 20 February 2023), his lack of engagement with the prison SMS
meant that he was not considered for it on this occasion, and he was not reminded
of the risks of overdosing after a period of abstinence. Mr Gresham was a long-term
user of opioids and for people with histories like his, there is an elevated overdose
risk on leaving prison. The post-mortem report did not show that opioids were a
factor in Mr Gresham’s death, so the possession of naloxone is not relevant to this
death, but his case does illustrate a gap in provision.
34. Mr Gresham’s COM said there had been a recent change in local practice and
COMs now automatically check with the community SMS providers prior to release
to confirm if a case is open to them and to determine if a new referral is needed.
She said that the local SMS try to accommodate COMs sending people to them
immediately, instead of waiting for forms to be processed. She said this is why she
directed Mr Gresham to go to the SMS on the day she met him after his release
from prison. He did not go. Following the feedback from the accommodation key
worker on 13 April, the COM intended to follow this up with a drugs test at Mr
Gresham’s next visit to the probation office. This opportunity did not arise because
Mr Gresham died before his appointment.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
35. Mr Gresham was resistant to compliance as well as to the help that was available to
him. We found no deficits in the prison or probation services provisions for Mr
Gresham, and make no recommendations.
Good practice
36. We are encouraged by two areas of good practice we encountered in this
investigation.
37. The first is the local probation practice to coordinate with community SMS providers
prior to prisoner release as discussed above.
38. The second is the SMS teams in Hull and HMP Humber encouraging released
prisoners to wear wrist bands that identify them as potentially needing treatment
with naloxone in their possession in the event of a suspected opioid overdose. Mr
Gresham was issued with one of these the previous October and the SMS team
leader told the investigator that there was a high take up of the wrist bands.
Inquest
39. The inquest into Mr Gresham’s death concluded on 11 December 2024. It found
that Mr Gresham’s death was drug related.
Adrian Usher
Prisons and Probation Ombudsman December 2023
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE