Lucas Kidd

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Independent investigation into
the death of Mr Lucas Kidd,
on 19 October 2023, following
his release from HMP Ranby
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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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 been investigating 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 Lucas Kidd died of cocaine, buprenorphine and pregabalin toxicity on 19
October 2023, following his release from HMP Ranby on 13 October 2023. He was
34 years old. I offer my condolences to those who knew him.
5. We did not identify any significant learning and we make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Kidd’s death on 24 October 2023.
7. The PPO investigator obtained copies of relevant extracts from Mr Kidd’s prison
and probation records and interviewed the community offender manager and senior
probation officer on 25 June. Transcripts of the interview are annexed to this report.
8. We informed the Procurator Fiscal’s office of the investigation (as Mr Kidd died in
Scotland). They provided us with a copy of the post-mortem and toxicology report.
We have sent the Procurator Fiscal a copy of this report.
9. We contacted Mr Kidd’s mother to explain the investigation and to ask if she had
any matters she wanted us to consider. She did not have any questions. Mr Kidd’s
sister asked us for a copy of the report.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Kidd’s family received a copy of the draft report. While they raised some
concerns about our report, we were not provided with any further information.
Background information
HMP Ranby
12. HMP Ranby is a category C adult male training and resettlement prison in
Nottinghamshire. Nottinghamshire Healthcare NHS Foundation Trust provides
physical and mental health services, including substance misuse, at Ranby.
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 and prepare reports to advise the Parole Board. They have
links with local partnerships to which they refer people for resettlement services,
where appropriate. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision, where applicable.
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Key Events
14. On 13 October 2022, Mr Lucas Kidd was convicted of driving under the influence
and a number of other driving-related offences, including the theft of a vehicle. He
was sentenced to 17 months in prison. On 30 January 2023, he was released on
licence but was arrested on 10 April for further driving offences.
15. On 11 April, Mr Kidd was convicted and sentenced to 20 weeks in prison. (He had
to serve the full 20 weeks in prison because his probation officer had also recalled
him for not attending probation appointments.)
16. That day, Mr Kidd was sent to HMP Leicester, where he told a nurse that he had
used heroin and cocaine every day before returning to prison. He was prescribed
methadone (an opiate used to treat drug addiction) and it was agreed that he would
move to Espranor (an alternative opiate substitute) before leaving prison.
17. On 20 April, a resettlement officer completed a basic custody screen for Mr Kidd.
She noted that he would be homeless on release and his Community Offender
Manager (COM) should refer him to the local authority for help in finding
accommodation and to Commissioned Rehabilitative Services (CRS which works in
partnership with probation staff to support post-release rehabilitation) within 56 days
before his release.
18. On 5 May, Mr Kidd’s COM completed an assessment of Mr Kidd’s risks and needs
in the community. She assessed that he posed a medium risk to the public and
known adults.
19. On 30 May, Mr Kidd was transferred to HMP Ranby. Following an initial health
assessment with a nurse, Mr Kidd was referred to the substance misuse team and
the mental health team. He had previously been diagnosed with acute transient
psychosis disorder for which he took medication. He told her that he was waiting for
an attention deficit hyperactivity disorder (ADHD) assessment.
20. On 2 June, a nurse from the substance misuse team met Mr Kidd to discuss his
drug use. The nurse warned him about the dangers of drugs, including Spice (a
psychoactive substance), cocaine and opiates.
21. On 3 June, it was recorded that Mr Kidd was to remain on methadone which would
be gradually reduced over the coming months and the substance misuse team
would see him every four weeks.
22. On 6 June, Mr Kidd emailed the healthcare team to say that he was still hearing
voices and seeing things. He said he had been told that his medications would be
increased but he had not heard anything. He asked for this to be resolved as soon
as possible. Later that day, a nurse saw Mr Kidd. He noted that Mr Kidd had said he
had visual and oral hallucinations and that his morning dosage of quetiapine (an
antipsychotic medication) was not enough. He noted that Mr Kidd would be
allocated a mental health nurse and was due to have a medication review with the
doctor.
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23. On 8 June, a prison offender manager (POM) met Mr Kidd who said that he was
unhappy that he had been recalled. He said he was not interested in engaging in
offence-focused work.
24. On 15 June, a nurse met Mr Kidd. They talked about his symptoms when his mental
health deteriorated, coping strategies and how he could access support in prison.
They discussed his medication dosage and Mr Kidd was told that any change would
need to be explored with a psychiatrist.
25. On 20 June, a management oversight supervision discussion took place between
the COM and a Senior Probation Officer, who was her supervisor. They noted that
Mr Kidd was not engaging with her because she had recalled him.
26. On 21 June, Mr Kidd was discussed at a mental health multidisciplinary meeting. It
was agreed that he should see a psychiatrist.
27. On 22 August, a nurse from the substance misuse team carried out a thirteen-week
review and agreed that Mr Kidd could change from methadone to Espranor a week
or two before his release. Mr Kidd declined the offer of naloxone (which can reverse
the effects of an opioid overdose). There is no record to explain why.
28. On 23 August, a prison psychiatrist met Mr Kidd and noted that he did not want an
increase in his medication. He concluded that Mr Kidd’s medication did not need to
be changed. He asked the nursing team to follow up on his ADHD assessment.
29. A nurse conducted monthly mental health reviews with Mr Kidd but had no
particular concerns.
30. 0n 4 September, following a second management oversight session, the Senior
Probation Officer noted that the COM had been trying to contact Mr Kidd, but he
was refusing to engage. She noted that Mr Kidd would be homeless on release and
the COM would try to engage with him through the email a prisoner scheme (which
enables approved people to contact a prisoner by email). The COM told the
investigator that she never contacted Mr Kidd using email a prisoner and he did not
contact her either.
31. The Senior Probation Officer told the investigator that because Mr Kidd was
managed as an integrated offender (which involves probation working very closely
with other agencies to manage an individual) to try to engage him, she would have
advised the COM to use police colleagues, refer him to peer mentoring and, where
appropriate, contact his family members to try to build a relationship before his
release.
32. That day, the COM made an accommodation referral to Nacro (a social justice
charity that supports individuals in areas such as housing and education) and a
referral to Leicester City Council. HMPPS has a legal duty to refer prisoners to the
local authority if they are at risk of homelessness on release from prison.
33. The medical records on 20 September indicate that a release pack had been
prepared for Mr Kidd, including information and infographics on drug harm reduction
and how and when to use naloxone.
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34. On 22 September, a prison resettlement officer carried out a pre-release review
with Mr Kidd to discuss his resettlement needs. It was recorded that Mr Kidd would
be homeless on his release and his COM had submitted a CRS referral for help
with accommodation. Mr Kidd told her that he had engaged with the mental health
team in prison and was registered with a GP in Leicester. He said that he had
misused drugs previously and intended to work with substance misuse services in
the community.
35. On 26 September, a nurse asked for an appointment for Mr Kidd with Turning Point
(a community-based substance misuse team) in Leicester so he could continue to
access support once released.
36. On 29 September, the COM made a second housing referral to Rutland County
Council under the legal duty to refer those at risk of homelessness. She told the
investigator that two weeks before Mr Kidd’s release, she had a video call with him
to tell him where his housing advisor was based. She said that Mr Kidd had
expected the video link to be with housing and not probation.
37. On 6 October, a nurse visited Mr Kidd to discuss his release arrangements. She
told him that if he was not notified of an appointment with Turning Point before his
release, he should go there before 4.00pm on the day of his release. She gave him
advice about the use of illicit drugs and offered him a naloxone kit which he again
declined. There is no record why he declined it.
38. On 9 October, the prison was notified that Mr Kidd had an appointment at Turning
Point on 19 October. It is not clear from the records if this information was passed
on to Mr Kidd.
39. That day, a nurse completed her last review. Mr Kidd said that he had received his
mental health discharge plan and letter for his GP. He was told that he would be
given seven days of medication on release. No concerns were noted.
40. On the same day, Mr Kidd also had a meeting with CRS to discuss his
accommodation post-release. It was recorded that the referral to Rutland County
Council needed to be chased up and Mr Kidd should contact them on the day of his
release to make a homeless declaration and to give them a letter from the
healthcare team about his medical information. It was also documented that
referrals would be made to other accommodation projects (outside of Leicester) and
that Mr Kidd would be supported to explore private, rented accommodation. A
follow-on appointment with the CRS provider was booked for 18 October.
41. The COM told the investigator that a referral to HMPPS’ Community
Accommodation Service (CAS3) was not made because the scheme was very new
and due to the limited number of beds, it was only offered to a certain category of
service users ‘by invite only’ based on availability of accommodation and the
suitability of the individual. (CAS3 is open to adult prison leavers who are at risk of
homelessness on release from prison. The service provides access to up to 84
days of accommodation.)
42. On 13 October, the substance misuse team saw Mr Kidd before his release. It was
recorded that Mr Kidd had his Espranor and had no concerns about his release. He
was given a release letter and harm minimisation information. He was again offered
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naloxone but declined. He was then released on licence, homeless. He had to meet
his COM at 1.00pm but did not attend the appointment.
43. On 15 October, Mr Kidd’s licence ended and he started a period of post-sentence
supervision, the conditions of which included keeping in touch with probation and
attending Turning Point appointments.
44. On 16 October, Mr Kidd failed to attend another appointment at the probation office.
An enforcement letter was sent to the address of one of his parents and the police
were notified.
45. On 18 October, Mr Kidd failed to attend a housing appointment with CRS.
46. On 19 October, Mr Kidd became unwell while travelling in a car in Scotland as a
passenger. Witnesses, who were travelling with him, told the police that Mr Kidd
had been taking drugs in the car. They said that Mr Kidd got out of the car at a
service station, where he collapsed and had a seizure. Members of the public tried
to help and performed CPR but Mr Kidd could not be resuscitated. Paramedics
arrived at 11.28am and Mr Kidd was pronounced dead at 12.10pm.
Post-mortem report
47. The post-mortem report concluded that Mr Kidd died of cocaine, buprenorphine and
pregabalin toxicity. The toxicology examination showed a massively elevated level
of cocaine in the blood. Pregabalin (which had not been prescribed to him) was also
detected at a toxic/fatal level in the toxic/fatal range.
Inquest
48. The Procurator Fiscal’s office informed the PPO that a Fatal Accident investigation
did not take place.
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Findings
Substance misuse
49. Mr Kidd had a history of substance misuse. He was given appropriate support to
address his substance misuse issues while at Ranby. He was reviewed in a timely
manner when he was recalled to prison, was placed on a methadone detoxification
programme and was then prescribed Espranor before his release. The substance
misuse team appropriately warned him of the risks of taking drugs and offered him
naloxone a number of times in preparation for his release. Although Mr Kidd
repeatedly declined it, he was appropriately referred to the community substance
misuse team (although it is not clear from the records whether he was told of this).
Pre-release engagement and planning
50. Homelessness on release from prison is a significant and complex challenge. Like
many leaving prison, Mr Kidd had significant vulnerabilities: a history of substance
misuse, poor mental health and homelessness.
51. When we asked the COM why Mr Kidd’s housing referrals were only made within
the final five weeks of his sentence, she told us that she had previously made
referrals in January 2023 (before he returned to custody) and as they were not
starting a new application, there was no need to do them earlier. She said that she
would routinely make a referral thirteen weeks before a prisoner was due to be
released but this was not necessary for Mr Kidd due to his previous applications.
She also explained that even when a local authority accepted that they had a duty
to provide accommodation, the prisoner was still required to present as homeless at
the council office following their release from prison. It was not until this point that
the local authority would seek to place them in accommodation which was normally
temporary in the first instance.
52. We identified that there was no record of any contact between Mr Kidd and his
COM following his recall into custody. She told the investigator that she had had
two conversations with Mr Kidd while he was in prison. The first was in his first three
weeks back in prison and the second was two weeks before he was due for
release. She said that in the first meeting, Mr Kidd had told her he had no intention
of engaging with probation, either in custody or after release. She said that at the
second meeting, Mr Kidd had only turned up as he thought the meeting was with a
housing professional and not her.
53. The COM appropriately discussed Mr Kidd’s non-engagement with her supervisor
(the Senior Probation Officer) on 20 June and 4 September. The supervisor
suggested that she should try to make contact using email a prisoner. The
supervisor told the investigator that she would also have suggested other options to
her to try and re-engage Mr Kidd. The COM told the investigator that she did not try
to contact Mr Kidd by email as she did not know how to use the email a prisoner
system.
54. The Senior Probation Officer explained that it was not always possible to track
actions agreed at management oversight sessions because a senior probation
officer may manage a team of 15 people, with in excess of 200 cases each.
However, she said she generally asked COMs to update her on cases that they had
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previously discussed. She explained that due to the caseload volumes, these
sessions typically focused on high risk or complex cases, or where the practitioner
needed help or advice.
55. The Senior Probation Officer told us that Mr Kidd’s engagement with probation had
always been poor, and he often did not engage with probation and the services
offered to him. She acknowledged that they should have kept trying to engage with
him regardless but also told us that at the time, the local probation delivery unit
(PDU) had been placed in ‘red status’ (when the PDU has less than 60% of staff in
place, with caseloads in excess of 120% for four weeks or more). She told us that
this meant that staff had to prioritise cases and tasks. While it would have been
better if the COM had tried more proactively to engage Mr Kidd, we recognise the
significant pressures faced balanced with the fact that Mr Kidd’s engagement had
been consistently poor. We therefore do not make a recommendation.
Regional Probation Director to note
56. It is important that probation staff record any actions they take and conversations
they have about an individual.
57. Senior probation officers should ensure that all of their staff know how to use the
email a prisoner system.
Adrian Usher
Prisons and Probation Ombudsman October 2024
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