Lewis Bennett

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Independent investigation into
the death of Mr Lewis Bennett
on 21 October 2024, following
his release from HMP Humber
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 Lewis Bennett died from heroin toxicity on 21 October 2024, four days after his
release from HMP Humber. He was 25 years old. We offer our condolences to
those who knew him.
5. Mr Bennett had a history of drug and alcohol misuse. He was offered naloxone (a
medication that rapidly reverses opioid overdose) on release but declined it.
6. Mr Bennett was not referred to community substance misuse services prior to his
release. Despite Mr Bennett having detoxed from opioids while in prison, we
consider that given his history of substance misuse, he should have been referred.
We bring this to the attention of the Head of the Probation Delivery Unit.
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The Investigation Process
7. HMPPS notified us of Mr Bennett’s death on 24 October 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Bennett’s prison
and probation records.
9. The Coroner for Bradford 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 Bennett’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
asked if Mr Bennett was offered naloxone and substance misuse support upon
release. We have addressed this in the report.
11. We shared our initial report with HMPPS. They found no factual inaccuracies.
12. We sent a copy of our initial report to Mr Bennett’s next of kin. They pointed out one
factual inaccuracy (an incorrect date), which has been amended in this report.
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Background Information
HMP Humber
13. HMP Humber is a category C resettlement prison for adult males. It is managed by
His Majesty’s Prison Service. Spectrum Community Health CIC provides healthcare
services at Humber.
Probation Service
14. 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
15. On 29 August 2024, Mr Lewis Bennett was sentenced to 18 weeks in prison for
possession of an offensive weapon. He was sent to HMP Hull.
16. Mr Bennett had a history of drug and alcohol misuse. When he arrived at Hull, he
received support from the prison’s substance misuse team and was placed on a
methadone maintenance programme. (Methadone is a synthetic opioid that is used
to treat heroin addiction as it reduces withdrawal symptoms.) However, the next
day, Mr Bennett told the substance misuse team that he no longer wanted to
engage with the methadone maintenance programme and that he wished to detox
without the support of services. Mr Bennett had no further involvement with the
substance misuse team after this.
Pre-release planning
17. On 9 September, Mr Bennett’s community offender manager (COM) completed an
approved premises referral. (Approved premises provide accommodation and
intensive supervision to individuals released from prison and are generally used for
offenders who pose a high risk of harm.)
18. On 16 September, Mr Bennett was moved to HMP Humber.
19. On 23 September, Mr Bennett’s COM completed a referral under the Community
Accommodation Service Tier 3 (CAS3) scheme, which provides accommodation to
prison leavers to prevent street homelessness at the point of release. The COM
also completed a Duty to Refer housing referral (for individuals at risk of
homelessness) to Bradford Council in preparation for release.
20. On 3 October, the COM held a video conference with Mr Bennett and discussed
accommodation plans. The COM told Mr Bennett about the approved premises and
CAS3 referrals. The COM also discussed plans for substance misuse support upon
release. Mr Bennett told the COM that should he require additional support for his
substance misuse issues, he would self-refer upon release. Therefore, the COM did
not complete a referral to community substance misuse services.
21. Later that day, the COM contacted the Dewsbury Approved Premises manager
about Mr Bennett’s application. They told her that they were unable to confirm if a
bedspace would be available for Mr Bennett’s release date.
22. On 3 October, the COM was informed by CAS3 accommodation that Mr Bennett
had been accepted by Mears Housing and a bedspace was available for his
release.
23. On 4 October, the COM and the senior probation officer (SPO) discussed the lack
of confirmed approved premises placement and Mr Bennett’s ongoing risk of
homelessness upon release. They decided to withdraw Mr Bennett’s approved
premises application and accept the CAS3 accommodation to avoid Mr Bennett
being street homeless upon release.
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Release from Humber
24. On 17 October, Mr Bennett was released from Humber. The prison’s substance
misuse team offered him naloxone prior to release but he declined it. He gave no
reason.
25. Mr Bennett was released to CAS3 accommodation provided by Mears Housing.
26. Mr Bennett reported to Bradford Probation Office on the day of his release and had
an alcohol electronic tag fitted. However, Mr Bennett failed to attend an
appointment with Mears Housing and his support worker later that day.
27. On 18 October, the support worker contacted Bradford Probation Service and told
duty probation staff that Mr Bennett had missed an appointment. However, they
confirmed they had entered Mr Bennett’s room and found his personal belongings
there indicating to staff that he had been at the property.
28. The duty SPO and duty COM decided not to recall Mr Bennett as there was
evidence that he had been at the property. They agreed to review the situation after
the weekend.
Circumstances of Mr Bennett’s death
29. On 21 October, Mears Housing contacted probation for the second time and agreed
to conduct a joint unannounced home visit with probation staff at Mr Bennett’s
property.
30. Later that day probation staff attended the CAS3 accommodation accompanied by
Mears Housing support staff and found Mr Bennett dead at the property.
Post-mortem report
31. The post-mortem report concluded that Mr Bennett died from heroin toxicity.
Pregabalin use (a prescription medication that is widely abused as it enhances the
euphoric effects of heroin and other opioids) was listed as a contributory factor.
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Findings
32. Mr Bennett was appropriately referred for an approved premises place prior to
release. Approved premises provide a high level of supervision to help reintegrate
prison leavers back into the community. The SPO and COM subsequently withdrew
the approved premises application and accepted a CAS3 place instead. While
CAS3 accommodation does not have the same level of support and monitoring that
an approved premises provides, there was no guarantee that Mr Bennett would be
offered an approved premises place and had the CAS3 place not been accepted,
there was a risk that Mr Bennett would be released homeless. We consider that the
decision made by the SPO and COM was a reasonable one in the circumstances.
33. We found the decision to complete a joint home visit with CAS3 accommodation
staff was evidence of good practice.
Head of Probation Delivery Unit to Note
34. Mr Bennett’s COM did not refer him to community substance misuse services prior
to his release because Mr Bennett said he would self-refer if he needed support
after release. We consider that given Mr Bennett’s history of drug and alcohol
misuse, he would have benefited from a referral to the community substance
misuse team for relapse prevention work and ongoing support as part of the pre-
release planning. We bring this to the attention of the Head of Yorkshire and
Humber Probation Delivery Unit.
35. The inquest, held on 8 April 2025, concluded that Mr Bennett’s death was drug
related.
Adrian Usher
Prisons and Probation Ombudsman April 2025
6 Prisons and Probation Ombudsman
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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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