Lee Kenyon

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Independent investigation into
A rep
the death of Mr Lee Kenyon on
24 June 2023 following his
release from HMP Altcourse
on 19 June 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, 2024
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Contents
Summary………………………………………………………………………………………...1
The Investigation Process……………………………………………………………… …….3
Background information...................................................................................................4
Key Events………………………………………………………………………………………5
Findings………………………………………………………………………………………….8
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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. 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 Kenyon died of hanging on 24 June 2023, following his release from HMP
Altcourse on 19 June. He was 44 years old. We offer our condolences to those who
knew him.
Findings
5. Although Mr Kenyon had some risk factors for suicide, we found that prison and
probation staff had no reason to assess him as a raised risk of suicide in the time
pre and post his release. However, Mr Kenyon’s community offender manager
(COM) did not refer Mr Kenyon to the community mental health team on 6 and 20
June which would have been good practice.
6. The clinical reviewer concluded that the clinical care Mr Kenyon received at
Altcourse was of a good standard and equivalent to what he could have expected to
receive in the community. She was satisfied that Mr Kenyon was correctly referred
to the appropriate services for his physical health prior to release. She did,
however, identify some areas of concern relating to information sharing. A
comprehensive release plan had not been shared with all agencies prior to Mr
Kenyon’s release and a discharge assessment was not completed on the day of his
release.
Recommendations
• The Head of Healthcare should ensure that processes and systems are in place
regarding release and discharge planning for all prisoners known to healthcare
and who require ongoing healthcare input.
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The Investigation Process
7. HMPPS notified us of Mr Kenyon’s death on 11 July 2023.
8. The PPO investigator obtained copies of relevant extracts from Mr Kenyon’s prison
and probation records.
9. We informed HM Coroner for Warrington of the investigation. She 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 Kenyon’s father to explain the investigation
and to ask if he had any matters he wanted us to consider. Mr Kenyon’s father
raised some concerns, which are outside the remit of our investigation.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
12. Mr Kenyon’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Altcourse
13. HMP Altcourse is a category B prison which holds male prisoners who have either
been convicted or are on remand. It is managed by G4S. The physical, mental
health and substance misuse treatment provider is G4S. The clinical and non-
clinical teams are known as Stay out and recover (SOAR). Castle Rock Group
(CRG) provides secondary mental healthcare.
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 supervises people
throughout their licence period and post-sentence supervision.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Altcourse was in November 2021. Inspectors
reported that there was evidence among newly arrived prisoners that not all risk
factors were always identified or adequately addressed, and they recommended
that the vulnerabilities and risks of newly arrived prisoners should be properly
assessed, and adequate support and interventions offered. Inspectors noted that all
new arrivals were screened for alcohol and drug use and if necessary, they were
referred to a GP, ensuring clinical assessments took place promptly. However, they
found that there was very limited non-clinical SOAR team support available to
provide prisoners with psychosocial support and they recommended there needed
to be effective, joined up non-clinical substance misuse support available for
prisoners. They also reported the primary care health team prioritised those in
crisis, however due the shortage of staff, there were long delays in some prisoners
having an initial assessment, which meant risks may not have been identified
promptly.
HM Inspectorate of Probation
16. The most recent inspection of National Probation Service (NPS) Liverpool North
Division was in June 2023. Inspectors reported that the Probation Delivery Unit
(PDU) was rated inadequate overall. They found insufficient levels of contact
between probation practitioners and prisoners prior to their release in the
community.
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Key Events
17. On 27 February 2023, Mr Lee Kenyon attended court after being charged with
assault of an emergency services worker. A court Probation Officer completed Mr
Kenyon’s pre-sentence report. Mr Kenyon said that he believed he was suffering
from psychosis and that he often heard voices, but he had not sought medical
advice. He said he had previously had suicidal thoughts and attempted to take his
own life. When the court Probation Officer tried to discuss this in more detail, Mr
Kenyon said that it was not an issue now. This information was shared with a
Senior Probation Officer, who activated a mental health alert on Mr Kenyon’s
probation record on 5 March 2023, so that his Community Offender Manager
(COM) would be made aware.
18. That day Mr Kenyon was sentenced to 16 weeks in prison and sent to HMP
Altcourse.
19. A nurse completed Mr Kenyon’s initial health screen. Mr Kenyon said that he did not
have any thoughts of suicide or self-harm, but he reported current issues with
drugs. Mr Kenyon’s clinical opiate withdrawal scale (COWS - measures acute
opioid withdrawal) score was eight and he tested positive for cocaine and opiates.
He was placed on a methadone detoxification programme (used to treat heroin
addiction by reducing withdrawal symptoms and cravings).
20. On 6 March, a nurse from the primary care mental health team saw Mr Kenyon. He
said he had used heroin and crack cocaine for a long time, and that he would
smoke six bags of heroin and 20 rocks of crack per day in the community. She
noted from previous GP reviews that Mr Kenyon had experienced auditory
hallucinations. Mr Kenyon said that he suffered with anxiety and depression, but
due to not staying in one place for very long he did not regularly collect his
medication. He said he had had no current mental health concerns. She decided
that Mr Kenyon did not need any further intervention from the mental health team.
21. On 21 April, Mr Kenyon was released from Altcourse.
22. On 5 May, Mr Kenyon was recalled to prison for failing to attend his probation
appointments and his whereabouts at that time were unknown. He was later
arrested and sent back to Altcourse. His recall paperwork indicated that he had
suicidal thoughts in the past, was a drug user and drank alcohol excessively. Mr
Kenyon had said that he was hearing voices, and his behaviour was possibly due to
drug induced psychosis.
23. That day, a nurse completed Mr Kenyon’s initial health screen. Mr Kenyon said that
he had tried to hang himself in the community 12 months earlier, and that he had
psychosis but was not medicated for this. Mr Kenyon tested positive for cocaine,
cannabinoids, benzodiazepines, methadone and opiates; his COWS score was 12.
He was prescribed 40ml of methadone. She referred him to the mental health team
and the substance misuse team.
24. On 8 May, a nurse from the mental health team went to assess Mr Kenyon, but he
declined the assessment. Mr Kenyon said that he felt okay and that he tended to
feel more anxious in the community due to gang related issues and that gang
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members were after him for a burglary he did not commit. She noted no psychotic
symptoms were evident and there would be no further follow up from the mental
health team.
25. On 9 May, a practitioner from the substance misuse team completed Mr Kenyon’s
induction. Mr Kenyon said that he would like support with his recovery journey. The
next day, a practitioner from the substance misuse team completed Mr Kenyon’s
assessment. She noted that Mr Kenyon was stable on his 40ml methadone script,
and that he did not want to reduce it.
26. On 18 May, Mr Kenyon was released from Altcourse. He was released homeless.
27. Mr Kenyon failed to attend his initial probation appointment.
28. On 21 May, Merseyside police received a 999 call from Mr Kenyon. He told them
that he was being burgled. The police attended the address, but Mr Kenyon’s friend
told them that Mr Kenyon had taken crack cocaine that evening and was under the
influence. The police officers took Mr Kenyon to hospital for review.
29. At the hospital, a senior nurse advised the police officers that Mr Kenyon did not
meet the threshold to be sectioned under the Mental Health Act because he had no
diagnosed mental health disorders and his behaviour was believed to be an
episode of drug induced psychosis. While waiting to be seen by hospital clinicians,
the effects of the drugs wore off and Mr Kenyon said that he wanted to speak to
someone about his mental health. The police officers recorded in the police report
that Mr Kenyon said, 'I'd rather die by my own hand than someone else's’, and ‘If
they [the people he thought were after him] are going to kill me, I'd rather do it
myself'.
30. On 22 May, Mr Kenyon was recalled to prison for failing to attend his initial
probation appointment on 18 May. Mr Kenyon was taken to Altcourse.
31. That day, a nurse completed Mr Kenyon’s initial health screen. Mr Kenyon said that
he had anxiety, depression, psychosis and that he was hospitalised on 19 May due
to his psychosis. Mr Kenyon tested positive for cocaine and opiates and his COWS
score was 15. Mr Kenyon denied any history of suicide attempts (contradicting
earlier admissions) or any current thoughts of suicide or self-harm. Mr Kenyon was
prescribed 40ml methadone.
32. On 23 May, a practitioner from the substance misuse team saw Mr Kenyon and
gave him a leaflet about harm reduction and safer drug use.
33. On 25 May, a practitioner from the mental health team completed an assessment.
He noted there were no mental health concerns or evidence of anxiety or
depression, therefore he considered that it was not appropriate to re commence
antidepressant medication and Mr Kenyon was discharged from their service. At
interview, the Modern Matron for the mental health team at Altcourse said that Mr
Kenyon had a baseline mental health screening and there were no concerns raised.
He also denied thoughts of suicide and self-harm. She said that at that point, it was
not deemed necessary for any further input from the mental health team.
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Pre-release planning
34. Also on 25 May, Ms Annette Kelly a resettlement worker at Altcourse saw Mr
Kenyon to complete a pre-release assessment. Mr Kenyon said that he did not want
to go back to the St Helens area because people were after him and he was
scared. He said that he was not on any medication for his anxiety or depression and
asked to see the mental health team (Mr Kenyon had already been assessed and
deemed unsuitable for their service and not requiring medication).
35. On 31 May, a caseworker from Intervention Alliance (an organisation which
provides crime prevention services to prison and probation, to improve community
safety) met with Mr Kenyon. Mr Kenyon said that he suffered with depression and
psychosis, he did not want to return to St Helens because he felt under threat, and
that he wanted to go to Preston, but he had no local connection to that area. It was
noted if there was no local connection, his community offender manager (COM)
would need to write a report to Preston council supporting his move to that area.
The actions from the appointment included for the COM to complete a duty to refer
(DTR - The Homelessness Reduction Act 2017 requires prisons and probation
services to refer anyone who is homeless or at risk of becoming homeless within 56
days to a local housing authority) to the local council, for the caseworker to request
the supporting letter from the COM, and a possible DTR referral to be sent to
Preston council if the application was accepted. The COM approved the action plan
on 13 June. She did not make a DTR or send a supporting letter to Preston due to
Mr Kenyon having no local connection. However, she did make a DTR to St Helens
council who were responsible for housing Mr Kenyon.
36. On 6 June, the COM visited Mr Kenyon in prison. She discussed with Mr Kenyon
the reasons why he had not been attending his probation appointments in the
community, his circumstances at the time and issues with accommodation. Mr
Kenyon said that his mental health was not the best at that time. She admitted that
she failed to refer him to the community mental health team and said that this was
an oversight. We recognise that there is no policy or requirement for her to
complete this referral, and we note that he was recently discharged from the prison
mental health service. However, we consider that a referral to a community mental
health team would have been good practice. Given Mr Kenyon’s fluctuating mental
health presentation when he had his initial appointment with her, an early referral
would have ensured he had prompt access to mental health support in the
community, should he need it.
37. On 7 June, the COM made a DTR to St Helens council, and arranged an
appointment with Housing Options (an advice service designed to provide
information and advice on housing options for those in crisis) for Mr Kenyon once
he was released. He was offered a bed at a YMCA, but Mr Kenyon did not stay
there.
38. On 12 June, the COM made a CAS3 referral (CAS3-provides temporary
accommodation for up to 84 nights for homeless people leaving prison) to St
Helens. The CAS3 referral was rejected because Mr Kenyon had already been
offered accommodation at the YMCA.
39. On 16 June, a practitioner from the substance misuse team completed a structured
psychosocial intervention with Mr Kenyon and discussed naloxone kits. He gave Mr
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Kenyon advice on harm reduction and strategies on how to minimise his risks in the
community. During the appointment, Mr Kenyon said that he was at risk from other
prisoners. The practitioner informed the prison staff on the wing and Mr Kenyon was
moved to the segregation unit for his safety. Prison staff looked into his concerns
and found no evidence to substantiate his claims.
Release from HMP Altcourse
40. On 19 June, Mr Kenyon was released from Altcourse on Post Sentence Supervision
(PSS – those sentenced to less than two years in prison are released on PSS to
provide an additional supervision period to help with rehabilitation in the
community). He was released with a naloxone kit (which can reverse the effects of
an opioid overdose). He stayed with a friend.
41. Change, Grow, Live (CGL - a charity helping people with drugs and alcohol,
housing, justice and health and well-being issues) had arranged to pick Mr Kenyon
up from the prison gate and take him to his probation appointment. However, when
they arrived, Mr Kenyon had already left the prison.
42. Mr Kenyon was instructed to attend Knowsley and St Helens Probation Office at
2.00pm for his initial appointment with his COM, but he did not attend.
43. On 20 June, Mr Kenyon attended the probation office. He told his COM that he felt
he was being followed. He said that he was struggling with his mental health, and
he was suffering with his anxiety and depression. He said that he was willing to
engage with services to get help. She told Mr Kenyon to call 111 or go to a hospital
if he was feeling suicidal. Mr Kenyon believed that his life was at risk due to people
being after him for something he said he had not done. She said that there was no
intelligence to support this, and Mr Kenyon could not give her any further
information about his risk, so she contacted the local police who informed her that
they had no information to corroborate Mr Kenyon’s claims. She did not refer Mr
Kenyon to the community mental health team following this appointment.
Circumstances of Mr Kenyon’s death
44. On 27 June, the police informed HMPPS that Mr Kenyon had died.
45. On the evening of 23 June, Mr Kenyon presented himself at Warrington hospital
feeling suicidal and asked for help. He was assessed by the psychiatric team who
referred him to the gateway team for an assessment. While Mr Kenyon was waiting
to be assessed, he went outside the hospital and took 16 paracetamol tablets with
alcohol. When he returned to the hospital, they treated him appropriately for the
overdose. Mr Kenyon then went into the hospital toilets and hanged himself in a
cubical using his shoelace. A member of the public discovered Mr Kenyon’s body.
Post-mortem report
46. The post-mortem report concluded that Mr Kenyon died from hanging. A toxicology
report found that Mr Kenyon had taken methadone some time prior to his death
which was consistent with therapeutic dosage.
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47. At the inquest held on the 26 April 2024, the coroner concluded Mr Kenyon died by
suicide.
Findings
Assessment of Mr Kenyon’s risk of suicide and self-harm
48. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of suicide or self-harm posed by prisoners with these risk factors and
should act appropriately to address any concerns. Mr Kenyon had a number of risk
factors that increased his risk of suicide and self-harm. He had a history of
attempted suicide, depression, anxiety, episodes of psychosis and drug misuse.
49. Mr Kenyon gave no indication to staff that he was at increased risk of suicide during
his time in prison and he was not subject to suicide and self-harm prevention
procedures. Staff referred him to the mental health team, but he declined their offer
of support. We are satisfied that the prison took reasonable steps to assess his
mental health needs.
50. We found the COM was aware of Mr Kenyon’s ongoing mental health issues and
discussed this with him on two occasions. Mr Kenyon’s complex behaviour, and
substance misuse issues and his reluctance to engage in supervision made it
difficult for the COM to build an accurate picture of the risk he posed to himself, and
we do not think she could have foreseen his actions. However, given Mr Kenyon’s
complex and fluctuating mental health presentation and lack of formal diagnosis, it
would have been good practice for a referral to have been considered to ensure Mr
Kenyon had timely access to mental health services, in the event he needed it. We
recognise that although this referral was not made, she might have discussed this
further with Mr Kenyon in any future appointments.
Substance Misuse
51. Mr Kenyon had a history of substance misuse. While he was in prison, he was seen
regularly by the SMS team and was warned about the risks and dangers of taking
drugs. He was also trained in the use of naloxone and was released with a supply
of this. Mr Kenyon was appropriately referred to the community substance misuse
team (CGL) prior to his release to ensure he would be supported in the community.
Arrangements were made for workers from CGL to pick Mr Kenyon up from the
prison gate and take him to his probation appointment, however when they arrived,
Mr Kenyon had already left the prison. We are satisfied that the prison and
probation services did all they could to manage the risks associated with his
substance misuse.
52. The clinical reviewer concluded that Mr Kenyon had a history of using illicit drugs
and was not taking his prescribed medication as directed, which would have had a
negative impact on his mental and physical health.
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Mental Health
Clinical care
53. The clinical reviewer concluded that Mr Kenyon received a good standard of clinical
care which was equivalent to what he could have expected to receive in the
community.
54. She did, however, identify a concern regarding information sharing. A
comprehensive release plan from the prison substance misuse and healthcare team
was confirmed but not shared with all services prior to Mr Kenyon’s release to
ensure continuity of care on release. We recommend:
The Head of Healthcare should ensure that processes and systems are in
place regarding release and discharge planning for all prisoners known to
healthcare and who require ongoing healthcare input.
55. Mr Kenyon was assessed by the mental health team on several occasions during
his time at Altcourse. However, he was discharged from their service on each
occasion. There was evidence in his medical records that he had a history of
hallucinations, but several health professionals believed Mr Kenyon’s behaviour
was drug induced, and he was not diagnosed with any mental health problems.
Therefore, he was not supported by the mental health team in prison and no referral
to the community mental health team was completed.
56. The clinical reviewer concluded that she had no concerns about the mental health
care Mr Kenyon received during his time at Altcourse. She noted that Mr Kenyon’s
medical records stated he had a diagnosis of mixed anxiety and depression, and he
was previously prescribed mirtazapine (antidepressant). However, he did not take
this regularly and therefore would not have had the adequate levels of medication in
his system to provide him with the required benefits.
57. A mental health alert was activated on Mr Kenyon’s probation records, to ensure his
COM was made aware. Mr Kenyon also told her twice that he was struggling with
his mental health, once when she visited him in prison on 6 June and again when
Mr Kenyon was released and attended his probation appointment on 20 June. She
admitted she failed to refer Mr Kenyon to the community mental health team after
he disclosed this information. She said that this was an oversight.
Head of Knowsley and St Helens Probation Delivery Unit to note
58. The Head of Knowsley and St Helens Probation Delivery Unit should ensure all
COMs understand their responsibilities within release planning and are aware of the
need to complete relevant referrals for prisoners with mental health needs.
Adrian Usher
Prisons and Probation Ombudsman December 2024
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