Louis Maniatt

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Independent investigation into
the death of Mr Louis Maniatt,
a resident at Ty Newydd
Approved Premises, on 22 April
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, 2026
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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.
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.
Mr Louis Maniatt died of butane toxicity on 22 April 2023 at Ty Newydd Approved
Premises. He was 43 years old. I offer my condolences to Mr Maniatt’s family and friends.
Mr Maniatt was the second resident to die at Ty Newydd in three years.
Mr Maniatt had been released from prison slightly less than a month before his death. He
had a history of substance misuse and mental health issues. Generally, staff provided
reasonable care and he presented minimal concerns. However, on the morning that Mr
Maniatt died, a residential worker did not carry out a thorough welfare check.
This version of my report, published on my website, has been amended to remove the
names of staff and residents involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman February 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
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Summary
Events
1. Mr Louis Maniatt was sentenced to 90 months in prison for robbery. He was
released from HMP Oakwood to Ty Newydd Approved Premises on 27 March 2023.
2. Mr Maniatt had a history of substance misuse and mental health issues. As part of
his induction, staff explained his licence conditions and the AP rules.
3. Mr Maniatt made contact with community mental health services and registered with
a GP. He was mostly compliant with his conditions and presented staff with no
concerns. Mr Maniatt admitted to smoking cannabis on one occasion on an
unspecified date before the 18 April, but he was engaging with substance misuse
services and the Probation Practitioner was not concerned.
4. In the week leading up to his death, Mr Maniatt ran out of his medication,
Olanzapine, for several days.
5. On 21 April, Mr Maniatt returned to the AP in the afternoon. He played pool with
other residents that evening before going to bed around midnight.
6. At 9.00am the next morning, a residential worker did not obtain a roused response
from Mr Maniatt as they were supposed to, but was not concerned about him,
believing he was asleep. At 11.00am, another residential worker found Mr Maniatt
unresponsive and further investigation revealed that he had died.
7. The post-mortem report examination and toxicology report confirmed Mr Maniatt
died from butane toxicity.
Findings
8. A residential worker did not carry out a welfare check to the required standard on
the morning of 22 April, but we are satisfied that the AP pursued appropriate
avenues to discipline the member of staff.
9. Mr Maniatt ran out of medication, but the AP now uses a different GP surgery which
prescribes more than just one week’s supply of medication at a time. We have also
asked the Head of Residential Public Protection for Probation Wales to ensure staff
understand the system for ordering more medication when necessary.
10. AP staff did not check Mr Maniatt’s next of kin’s contact details to ensure they had
the correct address. As a result, their letter of condolence was sent to the wrong
address.
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The Investigation Process
11. HMPPS notified us of Mr Maniatt’s death on 22 April 2023.
12. The investigator issued notices to staff and residents at Ty Newydd Approved
Premises informing them of the investigation and asking anyone with relevant
information to contact her. No one responded.
13. The investigator obtained copies of relevant extracts from Mr Maniatt’s probation
records.
14. The investigator interviewed the Head of Residential Public Protection for Probation
in Wales in November 2023.
15. We informed HM Coroner for North Wales of the investigation. The Coroner gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
16. The Ombudsman’s family liaison officer contacted Mr Maniatt’s daughter to explain
the investigation and to ask if she had any matters she wanted us to consider. She
wanted to know:
• how Mr Maniatt had died,
• why staff from the Approved Premises did not contact her mother to inform
her of the death; and
• what happened during staff’s morning checks on Mr Maniatt the day he died.
We have answered these questions in this report.
17. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
18. Mr Maniatt’s family received a copy of the initial report. They raised a number of
issues which did not impact on the factual accuracy of the report and have been
addressed in separate correspondence.
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Background Information
Ty Newydd Approved Premises
19. Approved Premises (formerly known as probation or bail hostels) accommodate
offenders released from prison on licence and those directed to live there by the
courts as a condition of bail. Their purpose is to provide an enhanced level of
residential supervision in the community, as well as a supportive and structured
environment. Residents are responsible for their own healthcare and are expected
to register with a GP.
20. Ty Newydd AP in Wales is managed by the National Probation Service. It holds up
to 17 men in single rooms. Each resident is allocated a key worker/offender
supervisor to oversee their progress and wellbeing and to ensure that residents
adhere to their licence conditions and the premises rules.
21. Residents are subject to AP rules in addition to any licence conditions they have
been given. They are not allowed to leave the building between 11.00pm and
6.00am. Ty Newydd is staffed 24-hours a day.
Previous deaths at Ty Newydd AP
22. Mr Maniatt’s death was the second at Ty Newydd in three years. The last death was
in November 2022. In that case, the AP also delayed contacting the family.
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Key Events
23. On 28 September 2018, Mr Louis Maniatt was sentenced to 90 months in prison for
robbery. Mr Maniatt was released on licence from HMP Oakwood on 27 March
2023. He had a history of substance misuse (including alcohol, crack, cocaine and
cannabis) and mental health issues. There were no reports of recent drug use or
suspicion of it in Mr Maniatt’s prison record (the last recorded suspicion in his prison
record was early 2020). He had engaged with the prison’s drug in-reach service at
the time and later with Alcoholics Anonymous.
24. Among other conditions, his licence said he should reside at Ty Newydd Approved
Premises, attend for drug testing and attend appointments, as directed, to address
his dependency on, or propensity to misuse, drugs.
25. When Mr Maniatt arrived at Ty Newydd on 27 March, a keyworker (also a Probation
Service Officer), a Probation Practitioner and another member of Ty Newydd staff
completed his induction. They told him he would be fitted with an alco-tag soon and
in fact this happened the same day. (An alco-tag is an electronic tag which monitors
alcohol consumption through the skin.) Staff told him naloxone kits were available
on site (naloxone can reverse the effects of an opiate overdose).
26. Mr Maniatt tested negative for substances. Residents would usually be tested again
sometime in the latter stages of their expected stay, unless there were suspicions a
resident was using drugs. There were no suspicions about Mr Maniatt and he was
not tested again, and his room was not searched during his stay at the AP.
27. Ms Elfryn completed a Support and Safety Plan and made a mental health referral
to the Hergest Unit. The keyworker also referred Mr Maniatt to Dechrau Newydd – a
project which supports drug and alcohol users in the criminal justice system to
improve their lives. She set a review date for 19 April and planned to visit Mr
Maniatt again in a couple of days.
28. On 28 March, Mr Maniatt registered with a GP.
29. On 29 March, the keyworker saw Mr Maniatt and noted on his Support and Safety
Plan that he had said it was important his mental health was controlled by
medication because he felt there was a strong link between his mental health and
substance misuse. He had previously spent time in a psychiatric facility following
episodes of self-harm.
30. On 4 April, the group facilitator from Dechrau Newydd told the keyworker that Mr
Maniatt had not engaged properly. It was agreed that one to one sessions would
probably work for him better. He attended one to one appointments on 11 and 18
April, and Dechrau Newydd raised no concerns.
31. On 11 April, the Probation Practitioner agreed that the condition requiring Mr
Maniatt to comply with a 12.00pm AP sign in could be removed. Middle of the day
sign ins help staff monitor how new residents are coping with increased freedom.
There were no concerns about Mr Maniatt abiding by his curfew conditions, he did
not appear under the influence at any point, he did not leave the AP often or raise
any suspicions which would have triggered a room search.
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32. On 12 April, Mr Maniatt attended his appointment at The Hergest Unit. He felt the
appointment had gone well, and he had been given a week’s supply of Olanzapine
with the expectation this would be available to him as a repeat prescription.
33. On 18 April, during a video-link meeting, Mr Maniatt told the Probation Practitioner
he had smoked a ‘spliff’ on an undisclosed date (but during the period his GP
arrangements were being finalised). The rest of the meeting concentrated on family
contact matters. By this point, the Probation Practitioner had officially taken on
another role, and Mr Maniatt’s supervision was incrementally transferring over to
another Probation Practitioner. She was at the meeting too.
34. On the same day, Mr Maniatt ran out of Olanzapine but there is no record that AP
staff reordered more. The AP’s usual process is that staff reorder more medication
when a resident is running low rather than waiting until they run out.
35. On 19 April, the keyworker reviewed Mr Maniatt and noted he had another
appointment scheduled at the Hergest Unit in May. (He had no Olanzapine on this
date either.)
36. On 20 April, a duty officer told Mr Maniatt he was running out of Olanzapine, but in
fact she later realised he had none left at all. She made arrangements to pick up
some more for him, which would be available the next day. He seemed well and
was not concerned. The AP’s medication log indicated that the medication was
available the next day.
37. On the afternoon of 21 April, Mr Maniatt signed out of the AP and said he was going
to town. He returned at 3.29pm and played pool with other residents. A residential
worker said he seemed happy and relaxed. Mr Maniatt went to bed around
midnight.
Events of 22 April
38. At 6.00am of 22 April, Residential Worker A carried out a routine morning check on
Mr Maniatt and received a response. (Residential workers are expected to get a
response which indicates the person is awake and it does not necessarily need to
be verbal).
39. At 9.00am, Residential Worker B carried out a further check on Mr Maniatt, He did
not reply when she knocked on the door. She unlocked the door and found he was
in bed, face up with his foot sticking out the end. She thought he was asleep and
locked his door and left. She did not attempt to get a response or check for any
signs of life.
40. At 11.00am, Residential Worker C carried out a check. He knocked on Mr Maniatt’s
door and called his name but got no response. He opened the door and found Mr
Maniatt lying on his bed with his legs hanging over the left side of the bed and his
arm across his chest holding a remote control. Mr Maniatt’s eyes and mouth were
open. He went into the room and touched his arm which was cold and stiff.
41. Residential Worker C pressed the panic alarm twice and waited for a colleague to
attend. No one came, so he went downstairs to get Residential Worker B. They
both went back to Mr Maniatt’s room. Residential Worker B felt for a pulse in Mr
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Maniatt’s neck and wrist, but there was nothing, and they considered he had died.
They went downstairs. Residential Worker B phoned for an ambulance and
Residential Worker C contacted the AP managers. Paramedics arrived and
confirmed that Mr Maniatt had died.
Contact with Mr Maniatt’s family
42. At 5.40pm that day, the police notified Mr Maniatt’s family of his death. It is standard
practice for the police to do this for AP deaths. The AP manager contacted the
family by phone the next day.
43. The Wales Approved Area Premises Manager was appointed as the single point of
contact for Mr Maniatt’s next of kin. She sent a letter of condolence to Mr Maniatt’s
next of kin on 26 April, offering support and in line with national instructions offered
to contribute to the costs of the funeral.
44. However, the Wales Approved Area Premises Manager sent the letter to the first
address the police had visited to break the news, which was the wrong address.
The Probation Service did not know the police had subsequently located the next of
kin living at a different address. On 4 May, Mr Maniatt’s sister contacted the AP
manager to make him aware of the correct contact details.
Support for residents and staff
45. The AP manager spoke to staff and residents who had had interactions with Mr
Maniatt and gave them information about how to access support if they needed it.
Post-mortem report
46. A post-mortem examination and toxicology tests gave Mr Maniatt’s cause of death
as butane (liquefied gas) toxicity.
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Findings
47. Staff at Ty Newydd AP made reasonable efforts to help Mr Maniatt and ensure he
got the help he needed during his stay at the AP.
Mr Maniatt’s substance misuse
48. Staff appropriately referred Mr Maniatt to Dechrau Newydd, a North Wales
substance misuse service. Mr Maniatt had not engaged well in a group setting and
arrangements were made for him to have one to one sessions instead. His last
appointment with them was on 18 April and they did not flag any further concerns
with the AP or Probation Practitioners.
49. Mr Maniatt died of butane toxicity, but he did not exhibit any obvious signs he was
abusing this substance. Butane cannisters are used to refill lighters and as Mr
Maniatt smoked, any discovery of a small amount of cannisters is unlikely to have
caused concern had he been searched. (Two canisters were found in his room after
his death.)
50. Although two residents told police that they knew Mr Maniatt abused butane, they
were not prepared to give any further information about this, so we cannot say
whether it was something staff should have detected. A residential worker
confirmed it was a relatively unusual substance for Approved Premises residents to
abuse.
51. Both Probation Practitioners were aware that Mr Maniatt had smoked cannabis at
an unspecified point since his release. Mr Maniatt was engaging with substance
misuse services and one instance of minor drug use did not initiate recall to prison.
The first Probation Practitioner could not retrospectively remember a great deal
about Mr Maniatt’s disclosure, but he was content Mr Maniatt was engaging with
Dechrau Newydd.
Welfare checks
52. On the morning of 22 April, Residential Worker B did not carry out the 9.00am
welfare check as thoroughly as is expected – notably failing to get a roused
response from Mr Maniatt. A disciplinary hearing concluded a 12 month final written
warning was appropriate. The warning was to be kept on her personal record for 12
months, effective from 7 August 2023. It was to be taken into account if any further
acts of misconduct occurred within this period.
53. The Wales Approved Area Premises Manager made us aware of a further incident
which resulted in Residential Worker B’s dismissal.
Head of Residential Public Protection for Probation Wales to note
Missed medication
54. The investigator asked the Wales Approved Area Premises Manager about Mr
Maniatt’s missed medication. The medication sheets implied he had missed some
doses in the week leading up to his death and on other occasions. Mr Maniatt had
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told staff that it was important his mental health was controlled by medication
because he felt there was a strong link between his mental health and substance
misuse.
55. The Wales Approved Area Premises Manager confirmed that standard practice at
the AP is that medication is ordered when a resident is low and not when it has run
out. The daily handover notes on Delius (Probation record) should advise if it has
been ordered and if the order had been followed up by duty officers – in Mr
Maniatt’s case this had been missed. Combined with the GP’s practice of only
prescribing Mr Maniatt’s medication one week at a time, this led to gaps in him
receiving his medication.
56. The AP now uses a different GP surgery and has not encountered any similar
issues. As a result, we make no recommendation. However, it is important that staff
keep track of medication stocks and understand the system in place for preventing
residents running out. The Wales Approved Area Premises Manager will wish to
consider this.
Contact with Mr Maniatt’s family
57. The police delivered the news of Mr Maniatt’s death to his sister after they
discovered she had moved address. AP staff did not check the family’s contact
details and their letter of condolence was sent to the wrong address. The Wales
Approved Area Premises Manager will wish to note the importance of checking the
address to ensure subsequent correspondence is sent to the correct place.
Inquest
58. At the inquest, held on 17 September 2025, the medical cause of death was
determined to be butane toxicity and the jury’s narrative verdict came to a
conclusion of ‘misadventure’.
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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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