Malcolm Bennett

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Malcolm
Bennett, on 16 July 2022
following his release from HMP
Bullingdon
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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 Malcolm Bennett died from heroin toxicity on 16 July 2022, following his release
from HMP Bullingdon on 14 July. He was 47 years old. We offer our condolences to
those who knew him.
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The Investigation Process
5. HMPPS notified us of Mr Bennett’s death on 10 August 2022.
6. The PPO investigator obtained copies of relevant extracts from Mr Bennett’s prison
and probation records.
7. We informed HM Coroner for Hampshire of the investigation. He gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
8. Mr Bennett did not provide details of a next of kin.
9. 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.
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Background Information
HMP Bullingdon
10. HMP Bullingdon is a category B local and resettlement prison, serving the courts of
Oxfordshire, Berkshire, Buckinghamshire and Wiltshire. It holds up to a maximum of
1,100 prisoners. Practice Plus Group provide healthcare and GP services and
Oxford Health NHS Foundation Trust provide mental health services at the prison.
Probation Service
11. 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 supervise people
throughout their licence period and post-sentence supervision.
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Key Events
12. On 12 February 2022, Mr Bennett was convicted of making threats with a
blade/sharply pointed article in a public place and was remanded to HMP
Bullingdon.
13. That day, a nurse completed Mr Bennett’s initial health screen. Mr Bennett reported
feeling suicidal, so the nurse started Prison Service suicide and self-harm
prevention procedures known as ACCT. He remained subject to ACCT monitoring
until 2 April.
14. Mr Bennett said he was on 40ml of methadone (an opiate substitute medication),
and that he last received it earlier that day. He said he had previously used illicit
drugs and suffered from depression, anxiety and PTSD (post traumatic distress).
The nurse referred Mr Bennett to the drug and alcohol team, Inclusion (a substance
misuse service that provide specialist holistic and comprehensive addiction services
within prisons). The Inclusion team saw Mr Bennett on 2 March, and provided
ongoing support to address his substance misuse, and he received methadone
maintenance therapy.
15. On 24 February, a nurse saw Mr Bennett after he said he had several mental health
issues. During the review, Mr Bennett asked to be prescribed diazepam to stop him
from re-offending. Mr Bennett told the nurse he had been diagnosed with PTSD,
schizophrenia, bipolar disorder and other mental illnesses, and said he bought
benzodiazepines on the street prior to coming to prison and believed this led to him
committing crimes. Mr Bennett also said that because the GP at the prison had
refused to prescribe him diazepam, he was now having epileptic seizures. The
nurse advised Mr Bennett to book an appointment with the GP to discuss this
further.
16. That day, a mental health nurse saw Mr Bennett. Mr Bennett said that he was not
willing to engage in therapeutic interventions unless he was prescribed medication.
She noted Mr Bennett presented medication seeking behaviours and considered
that he was not suitable for therapeutic interventions due to his lack of commitment.
17. On 27 April, Mr Bennett was sentenced to 10 months in prison. He remained at
Bullingdon.
Pre-release planning
18. On 6 May, an outreach worker from Two Saints (a homeless hub in Southampton,
providing services for people affected by homelessness) emailed the prison and
said that Mr Bennett had written to her to inform her of his release date, which was
14 July. She was Mr Bennett’s support worker in the community, and she hoped to
source accommodation for him on release. Prison staff forwarded the email to Mr
Bennett’s Community Offender Manager (COM), for information.
19. On 9 May, the COM emailed the outreach worker for clarification about 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) or a full gateway referral (an assessment service
for people who are homeless or threatened with homelessness). The outreach
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worker said that Mr Bennett had already been referred to the street homeless
prevention team to ensure his case would be reopened. She also said she had
completed his gateway referral and was going to send it in the post that day for Mr
Bennett to read and sign. She had contacted the resettlement team at Bullingdon
and requested they also send a referral to the street homeless prevention team.
20. That day, a senior support officer from the street homeless prevention team emailed
the COM and the outreach worker to let them know that they had reopened Mr
Bennett’s case and he had been allocated a housing officer at Southampton
Council.
21. On 7 June, Mr Bennett had a video link meeting with his outreach worker and a
team leader from Society of St James Supported Lettings (a homelessness charity
that provide a range of supported living services for those experiencing
homelessness, drug and alcohol issues and mental health problems), and assessed
Mr Bennett’s accommodation needs.
22. On 8 June, the team leader emailed the COM and informed him that Mr Bennett
had been accepted for supported living accommodation, but expressed fears about
placing him in accommodation with known drug users and suggested he would be
better suited to housing through the Integrated Offender Management scheme (IOM
- a supported housing organisation for people who pose a significant risk of violent
offending).
23. On 27 June, Mr Bennett had a video link meeting with his COM, the outreach
worker and a member of the IOM team. Mr Bennett declined the IOM referral
because he said it was not for him.
24. On 5 July, the team leader informed the COM that they would house Mr Bennett on
a temporary basis until a suitable room became available that met his needs. She
asked that Mr Bennett contact her on the day of his release so she could provide
him with the details and meet him at the address. The COM passed the information
to the prison to ensure Mr Bennett received further instructions on the day of his
release.
25. On 6 July, the clinical administrator within the substance misuse team contacted
Change, Grow, Live (CGL- a charity who offer support and advice to those facing
challenges with drugs or alcohol) to arrange an appointment for Mr Bennett once he
was released. An appointment was arranged for 15 July at 11.00.am. Mr Bennett’s
keyworker from Inclusion provided Mr Bennett with the appointment letter for CGL
just before he was released.
Post-release
26. On 14 July, Mr Bennett was released from Bullingdon. Mr Bennett was given
naloxone (which can reverse the effects of an opiate overdose) training in reception
and provided with a naloxone kit on release.
27. Mr Bennett was instructed to attend Southampton Probation Office at 2.00pm for his
induction with his COM, but Mr Bennett did not attend. Despite having the phone
numbers for both the COM and the outreach worker, Mr Bennet did not make
contact with them. He did not arrive at the accommodation found for him.
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28. On 15 July, Mr Bennett attended the Southampton Probation Office and told his
COM that he had not been able to attend his appointment the previous day because
he had heat stroke. The outreach worker participated in the meeting by phone and
told Mr Bennett that he needed to be at his accommodation no later than 3.30pm
that day. Later that day, Mr Bennett moved into the supported lettings
accommodation.
29. Mr Bennett did not attend his appointment with CGL.
Circumstances of Mr Bennett’s death
30. On 16 July, the police informed HMPPS that Mr Bennett had died.
31. At 10.26am that day, a friend of Mr Bennett, who was residing at the same address,
called 999 after he found Mr Bennett unresponsive on the floor. When the
paramedics arrived, they said there were early signs of rigor mortis and confirmed
Mr Bennett’s death.
32. Mr Bennett’s friend told the police that they had been taking heroin, crack cocaine
and spice (a psychoactive substance) together the night before into the early hours
of the morning and the last time they used drugs was at approximately 5:00am.
Post-mortem report
33. The post-mortem report gave Mr Bennett’s cause of death as drug toxicity (heroin).
Chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung
disease that causes obstructive airflow from the lungs) and left ventricular
hypertrophy (a thickening of the wall of the heart’s main pumping chamber) were
listed as contributory factors.
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Findings
Substance misuse services
34. Mr Bennett was given appropriate support to address his substance misuse during
his time at Bullingdon. Mr Bennett was reviewed in a timely manner and placed on a
methadone maintenance programme. Mr Bennett was also referred to the
community substance misuse team, CGL, to provide him with substance misuse
support in the community. He was trained to use naloxone and given a naloxone kit
on release.
Governor to note
35. Mr Bennett was managed under ACCT at Bullingdon between February and April
2022, three months before he was released. The Annex to Prison Service
Instruction (PSI) 64/2011, which sets out the ACCT process, notes that if a prisoner
who is due to be released has been supported using ACCT in the previous 12
months, relevant risk information from their most recent ACCT must be shared by
the Offender Manager Unit with probation colleagues prior to release wherever
possible.
36. Staff at Bullingdon did not share information about Mr Bennett’s ACCT or suicide
and self-harm risk with Mr Bennett’s COM prior to his release. As a result, Mr
Bennett’s COM was not fully aware of the risks Mr Bennett presented and was not
able to consider whether any additional support should be offered to Mr Bennett on
release.
Adrian Usher
Prisons and Probation Ombudsman February 2024
At the inquest held on the 16 January 2024, the coroner concluded that Mr Bennett died 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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