Lee-Ann Stent

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Independent investigation into
the death of Ms Lee-Ann Stent
on 5 July 2025, following her
release from HMP Downview
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, 2026
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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. Ms Lee-Ann Stent died from sudden adult cardio-respiratory failure caused by fatal
blood concentration of morphine and its metabolites (heroin) and cocaine use
(drugs overdose), on 5 July 2025, following her release from HMP Downview on 26
June. She was 35 years old. We offer our condolences to those who knew her.
5. Ms Stent had a long history of substance use, including heroin and cocaine use.
She was supported well in prison with her substance use issues, including through
opiate maintenance. Probation and healthcare staff prepared Ms Stent for release
by adjusting her prescription, providing her with and training her in the use of
naloxone, and referring her to community support agencies. Probation staff also
arranged appropriate housing for Ms Stent ahead of her release.
6. The clinical reviewers found that Ms Stent received commendable support from the
substance use team at Downview. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Ms Stent’s death on 10 July 2025.
8. The PPO investigator obtained copies of relevant extracts from Ms Stent’s prison
and probation records.
9. We informed HM Coroner for North London of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
10. NHS England commissioned two independent clinical reviewers to review Ms
Stent’s clinical care at HMP Downview. The clinical reviewers’ report was attached
as Annex 1.
11. The Ombudsman’s office contacted Ms Stent’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. Ms Stent’s sister said
that there was a delay by probation staff informing the family that Ms Stent was in
hospital, which has been addressed in the report. She also raised concerns not
within our remit and these have been addressed in separate correspondence.
12. We also shared the initial report with Ms Stent’s family. They did not make any
comments.
13. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Downview
14. HMP Downview holds sentenced women. Central and North West London NHS
Foundation Trust provides healthcare services, and the Forward Trust provides
substance use services.
Probation Service
15. 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
16. On 7 March 2025, Ms Lee-Ann Stent was convicted of motor vehicle interference,
theft, and assault by beating.
17. On 10 March, Ms Stent was sentenced to 30 weeks in prison, suspended for 18
months (a supervision order).
18. On 24 March, Ms Stent was convicted of a breach of her supervision order (motor
vehicle interference) and her 30-week sentence was therefore activated. She was
sent to HMP Bronzefield.
19. At the reception screening, healthcare staff recorded that Ms Stent had a history of
crack cocaine and heroin use. Staff placed Ms Stent on methadone maintenance
therapy (used to treat opiate dependence) and prescribed a dose of 30mls.
20. On 25 March, healthcare staff advised Ms Stent on harm minimization and
addressed the risks associated with the use of psychoactive substances (PS). The
next day, they created a care plan for Ms Stent.
21. On 28 March, Ms Stent told healthcare staff that she felt unwell with her current
methadone dose and was still having withdrawal symptoms. She asked to see the
substance use GP at the prison for a review. On 31 March, Ms Stent’s dose was
subsequently increased to 40mls.
22. On 4 April, Ms Stent was transferred to HMP Downview. On arrival, Ms Stent said
she would like to engage with Forward Trust (substance use support).
23. On 5 April, Ms Stent asked to be referred to the mental health team, due to previous
post-traumatic stress disorder and depression.
24. On 7 April, healthcare staff completed an initial substance use assessment. They
discussed drug therapy and treatment and advised Ms Stent to collect a naloxone
kit upon release. (Naloxone temporarily reverses the effects of opioid overdoses.)
25. On 11 April, Ms Stent’s community offender manager (COM) made accommodation
referrals for her. They also referred her to Forward Trust in the community. Ms
Stent had attended her pre-release assessment and probation staff said she
engaged about areas of her life that needed further interventions. She continued to
be prescribed of the same dose of methadone.
26. On 13 April, healthcare staff referred Ms Stent to a psychologist for trauma therapy.
A subsequent referral was accepted for Step 2 triage within psychological services.
27. On 17 April, healthcare staff developed a treatment plan for Ms Stent, who shared
past traumatic events with them. They discussed treatment options and identified
needs for psychological therapy. Ms Stent did not start therapy before her release.
28. On the 21 April, Ms Stent completed a two-week review with substance use staff.
She said that she wished to remain on the same dose of methadone and that she
had settled well on her wing. No issues were identified.
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29. On 29 April, healthcare staff referred Ms Stent to Living Safely drugs and harm
reduction 1-2-1’s and her release plan was completed, including to attend
community appointments and to reduce the methadone prescription. They provided
Ms Stent with further harm minimisation advice.
30. On 2 May, Ms Stent asked healthcare staff to reduce her methadone by 5mls per
week until she reached 20mls, so that she could then switch to buprenorphine (an
alternative substitution treatment for opioid dependence that is usually provided as
a tablet or dissolving wafer) for her release from prison. This was agreed.
Healthcare staff also asked Ms Stent to engage with the psychosocial team and
themselves for support and interventions. Staff discussed harm minimisation with
Ms Stent and the dangers of using PS and new synthetic opioids such as nitazenes.
31. On 29 May, prison staff spoke with incentivised substance free living (ISFL) staff, as
Ms Stent believed that moving to ISFL would support her work with Forward Trust
and her detox process. (Ms Stent subsequently moved to the ISFL on 6 June.)
32. On 3 June, healthcare staff saw Ms Stent for a care plan review. They noted that
she had been attending the psychosocial substance use group and would
commence taking buprenorphine on 9 June in preparation for her release.
33. On 5 June, Ms Stent told her COM that she had spoken to her prison offender
manager (POM) about her living situation and was waiting to be allocated housing.
Ms Stent suggested two areas where she would like to be placed. No other issues
or concerns were raised.
34. On 11 June, healthcare staff provided Ms Stent with naloxone training. Staff also
provided further harm minimisation advice to her.
35. On 18 June, Ms Stent told healthcare staff she would like to increase her dose of
buprenorphine in preparation for release This was implemented the next day, and
staff noted that the increase was due to the risk of relapse and a drug related
overdose/death on release.
36. On 20 June, probation staff arranged a community probation appointment for Ms
Stent in Harrow on the 27 June (the day after her release date). Ms Stent was still
waiting for confirmation of her release accommodation. Healthcare staff provided
harm minimisation advice to her.
37. On 24 June, probation staff confirmed that they had arranged a bed in community
accommodation service tier 3 (CAS3, providing temporary accommodation for up to
84 nights for people leaving prison who are at risk of homelessness) for Ms Stent
on release.
38. On 25 June, probation staff arranged an appointment for Ms Stent with Change,
Grow, Live (CGL - support for people with drugs or alcohol issues) in her release
area. The appointment was made for 27 June, and Ms Stent was informed of this
verbally and in writing.
39. The COM said that prior to release, referrals for Ms Stent were also made to
Advance Charity (women’s organisation delivering community-based support for
women and girls affected by domestic abuse, including those in contact with the
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criminal justice system) for emotional wellbeing, and drug dependency and recovery
support.
40. On 26 June, healthcare staff saw Ms Stent before she was released. They said she
looked fine and confident and they reminded her of harm reduction and the dangers
of PS use. Staff provided Ms Stent with a naloxone pack and recommended that
she attend narcotics anonymous (NA) meetings in the community. A GP prescribed
a supply of release medication, and details of Ms Stent’s buprenorphine prescription
were shared with CGL. Ms Stent was released from prison on licence.
Post Release
41. At around 2.00pm on 26 June, Ms Stent had a telephone discussion with Advance
Charity, who said she engaged well.
42. At 4.40pm, Ms Stent attended a probation induction. She was seen by a probation
colleague of her COM (who was on annual leave). Probation staff informed Ms
Stent of her appointments in the community. Probation staff noted that Ms Stent
went to her release accommodation.
43. On 27 June, Advance Charity staff prepared a care plan for Ms Stent. They noted
that Ms Stent said that she had not been referred for community drug support
following her release, and therefore noted an action to refer Ms Stent for support
around drug use. The caseworker also noted that they had signposted Ms Stent to
access community mental health support.
44. Ms Stent did not attend her pre-arranged appointment with CGL on 27 June.
45. On 2 July, CAS3 staff spoke with Ms Stent on the phone. They said she was
positive and upbeat. Ms Stent told staff she would not like any additional referrals at
the moment.
46. On 4 July, Ms Stent did not attend an appointment with her COM. The COM called
Ms Stent but received no answer. She emailed CAS3 staff and asked if they knew
whether Ms Stent was staying at her placement. Staff said Ms Stent had moved in
and a welfare check was scheduled with her at the address that week. (Ms Stent
died before this welfare check was completed.)
Circumstances of Ms Stent’s death
47. On 5 July, Ms Stent was admitted to hospital following a cardiac arrest. Hospital
staff made further attempts to resuscitate Ms Stent which failed. She died in
hospital at 7.53am. Ms Stent’s friend, who was with her when she collapsed, said
that he had been with Ms Stent the night before and that she had smoked heroin.
Contact with Ms Stent’s family
48. Ms Stent’s family said that they heard from an acquaintance of Ms Stent that she
had died. Probation staff told us that they did not inform Ms Stent’s family of her
death – this would usually be the responsibility of the police.
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Post-mortem report
49. The post-mortem report concluded that Ms Stent died from sudden adult cardio-
respiratory failure caused by fatal blood concentration of morphine and its
metabolites (heroin) and cocaine use (drugs overdose).
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Findings
Substance use support
50. The clinical reviewers concluded that the clinical care Ms Stent received at
Downview was of the required standard and equivalent to that which she could
have expected to receive in the community. In particular, they found that Ms Stent
received good support for her substance use and that the team should be
commended for their engagement with her. Prior to Ms Stent’s release, staff
arranged a discharge prescription and referral to community drug and alcohol
service (which Ms Stent did not attend).
51. The clinical reviewers made recommendations about recording continuity of care
plans and the use of opiate withdrawal assessment tools that the Head of
Healthcare will wish to consider and address.
Ms Stent’s mental health support in Downview
52. On 13 April, healthcare staff referred Ms Stent to a psychologist for trauma therapy.
A subsequent referral was accepted for Step 2 triage within psychological services.
The clinical reviewers found that the average waiting time for this was typically two
to three weeks, however Ms Stent waited for six weeks. This delay, combined with
her limited remaining sentence, meant there was insufficient time to commence any
meaningful group or one-to-one therapy before Ms Stent’s release.
Release arrangements
53. Ms Stent was at Downview for around 12 weeks. During this time, prison and
probation staff arranged for referrals to mental health and substance support
services for Ms Stent in prison. They also secured appropriate housing for her
ahead of release.
54. Ms Stent’s original COM was on annual leave so did not see or engage with Ms
Stent on release. However, the COM said there was no formal expectation of
contact with people who are under 12 months supervision and not under multi-
agency public protection arrangements (MAPPA). Therefore, probation staff had
indirect contact with Ms Stent through the POM before she was released. We found
evidence of this on 5 June, when Ms Stent was waiting to be allocated housing.
55. On 4 July, there was good practice by the COM on her return from leave. When Ms
Stent did not attend her probation appointment that day, the COM promptly liaised
with Ms Stent’s housing provider to try to establish her whereabouts.
56. We are satisfied that prison, probation and healthcare staff made sufficient efforts to
support Ms Stent in prison and the community.
Inquest
57. The inquest into Ms Stent’s death concluded on the 17 March 2026. The coroner
confirmed that Ms Stent’s death was drugs related.
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Adrian Usher
Prisons and Probation Ombudsman April 2026
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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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