Lee Hartley

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Independent investigation into
the death of Mr Lee Hartley on
31 January 2025, following his
release from HMP Doncaster
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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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 investigated 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. Mr Lee Hartley died from multiple drug misuse on 31 January 2025, nine days after
his release from HMP Doncaster. He was 52 years old. We offer our condolences to
those who knew him.
5. Mr Hartley was offered good support for his substance misuse issues while at
Doncaster. Substance misuse support was also put in place for when he was
released from prison.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Hartley’s death on 24 March 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Hartley’s prison
and probation records.
9. We informed HM Coroner for Doncaster of the investigation. They 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 Hartley’s next of kin, his sister, to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond.
11. We shared our initial report with HMPPS. They found no factual inaccuracies.
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Background Information
HMP Doncaster
12. HMP Doncaster is a reception and resettlement prison that holds category B male
prisoners who have been convicted, as well as those on remand. It is managed by
Serco. Practice Plus Group (PPG) provides physical and mental health care
services, as well as substance misuse treatment services.
Probation Service
13. 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.
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Key Events
Background
14. On 3 December 2024, Mr Lee Hartley was convicted of shoplifting and was
sentenced to 18 weeks in prison. He was sent to HMP Doncaster.
Pre-release planning
15. When he arrived at Doncaster, Mr Hartley told the reception nurse that he had a
history of anxiety, depression and substance misuse. He said that prior to coming to
prison, he was taking crack cocaine and heroin. He was also abusing illicit
prescription drugs, namely methadone (an opiate substitute), although he was not
on a prescribed methadone detoxification programme. The nurse arranged for him
to be monitored for opiate withdrawal symptoms over the following days. When
asked, Mr Hartley said he would like support with his substance misuse, so the
nurse completed a referral to the prison’s substance misuse service (SMS).
16. On 4 December, a recovery worker saw Mr Hartley to complete an initial substance
misuse assessment. Mr Hartley told the recovery worker that three weeks before,
he accidentally overdosed on heroin which resulted in the emergency services
being called who attended and administered naloxone (a medication used to
reverse the effects of opioid overdose). As a result, the recovery worker and Mr
Hartley completed a 1:1 session on overdose awareness which included advice to
not use drugs alone and to use small amounts to test their strength. The recovery
worker warned Mr Hartley about the dangers of mixing drugs with alcohol and how
this could further increase the risks of overdose. He also warned Mr Hartley about a
dangerous batch of heroin that had been reported in South Yorkshire and
Lincolnshire. (This batch was laced with carfentanil, an opiate thousands of times
more potent than heroin, so the risk of overdose was extremely high.) The recovery
worker told Mr Hartley what it looked and smelled like, and how he might be able to
recognise it. He gave Mr Hartley information on tolerance levels and overdose
awareness, including how to recognise the signs and symptoms of an overdose,
and what to do in the event of one. The recovery worker noted that Mr Hartley
showed a good understanding of this.
17. Mr Hartley said he would like to be released with a naloxone kit and would like to be
referred for substance misuse support in the community. Finally, Mr Hartley asked if
he could be prescribed a small amount of methadone to help with his heroin
withdrawal symptoms. The recovery worker advised him that he already had an
opiate substitution therapy (OST) assessment booked for 4.00pm that day. After the
appointment, the recovery worker completed a referral to Doncaster Aspire, a
community SMS treatment provider.
18. Mr Hartley did not attend his OST assessment. This was rearranged for the next
day.
19. On 6 December, Mr Hartley did not attend his OST assessment. This was again
arranged for the next day, however again, he did not attend.
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20. On 9 December, Mr Hartley attended his OST assessment. The nurse prescriber
assessed that Mr Hartley did not require a prescribed heroin detoxification
programme. The nurse reminded Mr Hartley about the risks associated with taking
drugs and gave advice on harm minimisation.
21. As Mr Hartley was due to be released from prison homeless, his community
offender manager (COM) completed a CAS3 housing referral (a scheme providing
temporary accommodation and support to prison leavers at risk of homelessness)
on 6 January 2025.
22. On 15 January, Mr Hartley was accepted onto the CAS3 scheme. His COM was
notified that temporary accommodation had been secured for him for a period of 84
days at an address in Doncaster.
23. On 21 January, Mr Hartley attended a pre-release appointment with his recovery
worker. The recovery worker warned Mr Hartley of his low tolerance after a period
of abstinence, and how this would make him more susceptible to overdosing. The
recovery worker told Mr Hartley that recently, some of the street drugs had been
found to be contaminated with substances such as Fentanyl and Nitazenes which,
due to their higher potency, had led to several deaths and numerous overdoses. It
was noted that Mr Hartley had a good understanding of the risks, and he said he
was going to try and abstain from taking drugs after his release from prison. Mr
Hartley completed the training on take home naloxone and was told he could collect
a kit from reception on the day of his release. Finally, the recovery worker gave Mr
Hartley a letter detailing his release appointment with Doncaster Aspire.
Release from HMP Doncaster
24. On 22 January, Mr Hartley was released from Doncaster with a naloxone kit, a copy
of his licence, and details of his probation and CAS3 induction appointments. He
attended Doncaster’s ‘departure lounge’ (offers prisoners advice and support with
accommodation, finances, employment, education and training immediately after
their release) and was met by a recovery worker from Doncaster Aspire. They
completed an initial substance misuse care plan that focused on relapse prevention,
and the recovery worker reminded Mr Hartley of the risks associated with substance
misuse and advised him how he could minimise these risks. The recovery worker
issued Mr Hartley his next appointment for 29 January at Prince’s House,
Doncaster.
25. Mr Hartley did not attend his induction at his CAS3 temporary accommodation at
2.00pm or his initial appointment at Doncaster Probation Office at 4.00pm.
26. Approximately an hour later, a resident welfare officer from the CAS3 temporary
accommodation telephoned Mr Hartley’s COM. He told her that Mr Hartley had
been taken to Doncaster Royal Infirmary after being found unresponsive by a
member of the public in Hexthorpe.
27. The next morning, the COM called the hospital and was told that Mr Hartley had
been discharged in the early hours. The COM relayed this information to the CAS3
temporary accommodation who advised her that if Mr Hartley did not attend the
accommodation for his induction by 5.00pm that day, then he would lose his bed
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space. The COM did not have a telephone number for Mr Hartley and therefore
could not contact him to tell him this.
28. Later that evening, Mr Hartley telephoned Doncaster Probation Office and asked for
the address of his CAS3 temporary accommodation. The duty officer told him that,
unfortunately, because he had not contacted either the accommodation service or
probation after his release the previous day, he had lost his bedspace. The duty
officer advised him to go to the local council office and present himself as homeless
and gave him details of his next probation appointment. Probation records note that
Mr Hartley became rude and abusive on the phone, so the duty officer ended the
call.
29. On 28 January, Mr Hartley did not attend his scheduled probation appointment.
Circumstances of Mr Hartley’s death
30. On 28 January, Mr Hartley’s partner found him collapsed and unresponsive, so she
called the emergency services. Paramedics attended and found Mr Hartley in
cardiac arrest. He was subsequently taken to hospital and admitted to the intensive
care unit (ICU). Mr Hartley remained in the ICU where medical tests showed he had
significant brain damage and multi organ failure. On 31 January, his family made
the decision to withdraw treatment and he died later that day.
Post-mortem report
31. The post-mortem report concluded that Mr Hartley died from hypoxic brain injury
caused by multiple drug misuse (synthetic cannabinoids, cocaine, diazepam and
pregabalin).
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Findings
Substance misuse support
32. Mr Hartley had a history of substance misuse. Although he was in prison for only
eight weeks, during this time, he was appropriately supported by the prison’s SMS
team and warned about the risks and dangers associated with substance misuse.
The prison promptly and appropriately referred Mr Hartley to Doncaster Aspire so
he had access to substance misuse support upon release. He was also trained in
the use of naloxone and released with a supply of this.
33. We are satisfied that Mr Hartley’s COM took appropriate measures to address his
substance misuse upon his release from prison. This included securing a space in
CAS3 temporary accommodation to ensure he was not homeless upon his release
from prison. Additionally, Mr Hartley’s COM added licence conditions to comply with
any requirements relating to addressing his substance misuse issues.
Good practice
34. Staff from Doncaster Aspire met Mr Hartley in the prison’s departure lounge after Mr
Hartley was released and reiterated messages about the dangers of drug use after
a period of abstinence.
35. We are satisfied that both the prison and probation services did all they could to
manage the risks associated with Mr Hartley’s substance misuse.
36. We make no recommendations.
Inquest
37. The inquest, held on 12 June 2025, concluded that Mr Hartley’s death was drug
related.
Adrian Usher
Prisons and Probation Ombudsman June 2025
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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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