Margaret Berry

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Margaret Berry,
on 30 May 2025, following her
release from HMP Styal
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 Margaret Berry died from pneumonia with chronic pulmonary obstructive
disease (a lung disease) on 30 May 2025 following her release from HMP Styal the
day before. She was 43 years old. We offer our condolences to those who knew Ms
Berry.
5. Ms Berry did not report any concerns about her physical health in the lead up to, or
on the day of her release. She was assessed by healthcare staff at Styal and did
not present as physically unwell. The clinical reviewer found that the care Ms Berry
received at Styal was equivalent to that which she would have received in the
community. The clinical reviewer made one recommendation, which did not impact
on her assessment of equivalence, that the Head of Healthcare will wish to address.
6. Ms Berry’s community offender manager (COM) appropriately prepared for her
release and ensured she had accommodation to go to.
7. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Ms Berry. We make no recommendations.
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The Investigation Process
8. HMPPS notified us of Ms Berry’s death on 5 June 2025.
9. The PPO investigator obtained copies of relevant extracts from Ms Berry’s prison
and probation records.
10. NHS England commissioned an independent clinical reviewer to review Ms Berry’s
clinical care at Styal. The clinical reviewer’s report is attached as Annex 1.
11. We informed HM Coroner for North Wales of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
12. The Ombudsman’s office contacted Ms Berry’s next of kin, her father, to explain the
investigation and to ask if he had any matters he wanted us to consider. He had no
questions but asked for a copy of our report.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
14. Ms Berry’s family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Styal
15. HMP Styal holds convicted and remanded female adult prisoners. The prison has
16 residential units, including a mother and baby unit. Spectrum Community Health
CIC provides healthcare and substance misuse services. Greater Manchester West
NHS Foundation Trust provides mental health services.
Probation Service
16. 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
17. On 13 August 2024, Ms Margaret Berry received an 18-month suspended sentence
order (SSO) for a theft offence. (A SSO is a custodial sentence that allows people
to serve their prison sentence in the community, if they comply with court-imposed
conditions. If they breach these conditions, the court can activate the sentence and
send them to prison.)
18. On 19 February 2025, Ms Berry appeared in court, charged with burglary offences.
She was resentenced to 20 weeks imprisonment and taken to HMP Styal.
19. During her first reception screening, Ms Berry told a nurse that she had chronic
obstructive pulmonary disease (COPD – a group of lung conditions) and asthma.
She was prescribed an inhaler. Ms Berry arrived at the prison with pregabalin
(prescribed for pain relief and to treat mental health conditions) and promazine
(prescribed as a sleep aid) which healthcare staff continued to prescribe.
20. Ms Berry had a history of several mental health conditions including multiple
personality disorders, schizophrenia (symptoms include hallucinations and
delusions) and attention deficit hyperactivity disorder (ADHD – symptoms include
impulsivity, hyperactivity, inattention and emotional dysregulation). She said she
had no thoughts of suicide or self-harm and declined a referral to the mental health
team. Ms Berry tested positive for cannabinoids and cocaine and disclosed daily
alcohol use.
21. During her second reception screening the next day, healthcare staff created
asthma and COPD care plans. The substance misuse team continued to monitor
Ms Berry, although she did not require detoxification medication for her withdrawal
symptoms.
22. On 21 February, a healthcare support worker confirmed that Ms Berry was under
the care of the community mental health team and received a monthly antipsychotic
depot injection for schizophrenia. She was referred to the mental health team to
continue her treatment.
23. On 13 March, Ms Berry attended an annual asthma review with a prison
pharmacist. She reported experiencing respiratory symptoms at night and said she
used her inhaler daily. The pharmacist scheduled a follow-up review in four to six
weeks, but this did not take place before her release.
24. On 2 April, Ms Berry was sentenced to 21 days in prison for breaching a criminal
behaviour order imposed in 2022. She served this sentence at the same time as her
original sentence.
25. On 3 April, the person appointed as Ms Berry’s COM during a previous sentence in
October 2024, visited her at Styal with an integrated offender management (IOM)
police officer. (IOM is a multi-agency approach with the police, probation, prisons
and other services to manage individuals who pose a high risk of reoffending). Ms
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Berry told them that prison had been beneficial for her and she agreed to referrals
for substance use and homelessness support.
26. On 15 April, Ms Berry was released. She attended her initial appointment at
Wrexham Probation Office at 12.00pm. Her IOM officer and a housing officer from
the local authority joined the appointment and completed paperwork with her. She
had a home visit scheduled for the following week.
27. On 23 April, IOM officers attended Ms Berry’s address for a home visit. She told the
IOM police officers that she was still struggling with her chest following a ‘flare up’
and planned on collecting medication from the GP. Ms Berry was not home when
IOM officer attempted a further visit on 30 April.
28. On 1 May, Ms Berry contacted the COM to notify her that she was unwell and to
check if she should still attend her appointment that day. This appointment was
rescheduled. On 6 May, Ms Berry updated her COM that a GP had prescribed her
antibiotics and steroid medication for her chest.
29. On 8 May, Ms Berry attended a probation appointment and reported no issues or
concerns. She also received her depot injection to treat schizophrenia.
30. On 15 May, the COM received an update from the police alleging that Ms Berry had
committed an offence of assault. She completed paperwork to recall Ms Berry to
prison for 14 days.
31. On 17 May, Ms Berry was taken to Styal. During her first reception screening, she
told a nurse that she felt ‘rough’ and was experiencing withdrawal symptoms from
taking drugs. She tested positive for buprenorphine (medication used to treat opioid
dependence which she had not been prescribed), cannabinoids and cocaine.
32. The following day, a nurse completed clinical observations (which involves checking
body temperature, blood pressure, pulse and breathing rate). They were within the
normal range.
33. On 19 May, Ms Berry saw a recovery worker who recorded that she did not meet
the requirement to be prescribed medication to treat opioid dependence as she did
not test positive for opioids. Ms Berry was upset by this due to complaining of mild
withdrawal symptoms and was advised to raise her concerns with healthcare staff.
Later that day, she was prescribed methadone (to treat opioid withdrawal
symptoms) with a gradually increasing dose.
34. On 20 May, healthcare staff referred Ms Berry to the long-term conditions case
management service. On 21 May, a psychiatrist reviewed Ms Berry and noted
concerns about the combination of prescribing promazine alongside depot
injections due to the potential risk of sedation, respiratory depression, hypertension
(high blood pressure) and hyponatraemia (low sodium level). The psychiatrist
suggested prescribing mirtazapine (an antidepressant) instead of promazine which
the GP subsequently actioned. On the same day, a nurse arranged for her to be
issued with naloxone (to reverse the effect of an opioid overdose) for 29 May in
preparation for her release.
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35. On 24 May, Ms Berry attended a key work session. (Key workers provide prisoners
with an allocated officer that they can meet regularly to discuss how they are and
issues they have.) She said she felt settled in prison and had no concerns.
36. On 29 May, Ms Berry was released from prison.
Pre-release planning
37. Prior to her recall, the Centralised Operational Resettlement, Referral and
Evaluation hub (CORRE - a central team in probation that assist with referrals to
services and interventions) completed sentence plan objectives around
accommodation, mental health support and social inclusion support on 3 April,
following a discussion with the COM on 1 April.
38. On 9 April, the COM confirmed Styal had contacted the community mental health
team to ensure continuity of care. On the same day, she requested that Ms Berry’s
substance misuse appointments be held at the probation office to promote
compliance. The COM also referred Ms Berry to a homelessness charity to work
with a senior support worker she was familiar with, as well as to a peer mentoring
service for literacy support.
39. On 23 May, the local authority approved Ms Berry’s return to the Community
Accommodation Service Tier 3 (CAS3 - a service open to adult prison leavers who
are at risk of homelessness on release which provides access to up to 84 days of
accommodation). The COM updated the prison and provided Ms Berry’s licence
conditions and reporting instructions to prepare for her release.
40. On 26 May, a pharmacy technician prepared a future prescription dated 23 June for
a combination inhaler to treat asthma and COPD. The following day, Ms Berry was
prescribed pregabalin for 3 June to last 14 days. A recovery worker also arranged
for Ms Berry to collect her methadone from a pharmacy from 30 May. Ms Berry said
she had no withdrawal symptoms.
41. Ms Berry’s COM identified that her offending was linked to substance use and
included drug testing and engagement with community substance misuse services
as conditions of her licence.
42. Ms Berry was instructed to attend Wrexham Probation Office on the day of her
release. She was aware of her licence conditions.
Post-release management
43. On 29 May, Ms Berry was released from Styal and provided with naloxone. She
was seen by healthcare staff before leaving the prison but refused to have her
clinical observations taken.
44. Ms Berry attended her probation appointment as required on 29 May. Although she
was running late due to issues with trains, she remained in contact with a probation
service officer throughout the day. Ms Berry explained that she had several
appointments on one day, including attending the job centre and collecting the keys
for her accommodation.
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45. During her probation appointment, the probation service officer reminded Ms Berry
that she needed to collect her methadone the next day, which she confirmed she
would. She told the probation service officer that she was looking forward to going
to a boxing gym the next morning. Ms Berry did not raise any issues or concerns
regarding her physical health during her appointment. Her next probation
appointment was arranged for 5 June.
46. Ms Berry also attended the substance misuse service for her induction appointment
and collected the keys to her accommodation that day.
Circumstances of Ms Berry’s death
47. On 30 May at 4.16pm, a neighbour visited Ms Berry’s flat and found her
unresponsive. The neighbour called the emergency services and alerted a nearby
police officer. Police attended and found Ms Berry on her sofa with no signs of life.
Paramedics attended and pronounced life extinct.
Post-mortem report
48. The post-mortem report concluded that Ms Berry died from pneumonia with COPD.
49. Toxicology reports indicated that Ms Berry had consumed methadone at a
concentration consistent with high therapeutic use. While this level is not
considered an overdose, it can increase the risk of arrhythmia (irregular heartbeat)
and respiratory depression (slow breathing), particularly when combined with other
substances. Pregabalin was also detected within the therapeutic range, and the
pathologist concluded that it may have contributed to the overall effects on
respiration.
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Findings
Clinical Care
50. In the days leading up to, and on the day of Ms Berry’s release, she did not report
any concerns about her physical health. Healthcare and prison staff did not observe
her to be physically unwell. She declined clinical observations upon release and did
not raise any health concerns when she subsequently attended her probation
appointment.
51. The clinical reviewer was satisfied that Ms Berry received appropriate medication to
treat her asthma and COPD. However, she noted healthcare staff did not liaise
directly with her community GP regarding these conditions. She also found no
evidence of a discharge letter being provided to the GP, which raised concerns
about continuity of care for her respiratory health.
52. The clinical reviewer found that Ms Berry received regular reviews while prescribed
methadone and had a comprehensive substance misuse care plan and release plan
in place. Healthcare staff ensured the community mental health team was aware of
Ms Berry’s release and that a follow-up appointment was arranged. The clinical
reviewer found appropriate support was in place to manage Ms Berry’s substance
misuse and mental health needs.
53. Overall, the clinical reviewer concluded that Ms Berry’s care at Styal was of a good
standard and equivalent to that which she would have received in the community.
She made one recommendation, which did not impact her assessment of
equivalence, which the Head of Healthcare will wish to address.
Accommodation
54. The COM appropriately prepared for Ms Berry’s release and liaised with the local
authority to ensure she was released with accommodation in place. She included a
licence condition requiring Ms Berry to engage with housing services to support
compliance and help her progress towards securing permanent accommodation.
Ms Berry was able to return to her accommodation upon release.
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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