Matthew Scott

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Matthew Scott,
on 17 June 2024, following his
release from HMP Lincoln
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 Matthew Scott died from multiple drug toxicity on 17 June 2024, four days after
his release from HMP Lincoln. He was 27 years old. We offer our condolences to
those who knew him.
5. We consider that Mr Scott should have been offered naloxone (to reverse the
effects of an opioid overdose) on release.
Recommendation
• The Head of Service Delivery for substance misuse should satisfy themselves that
the local policy on the offer and issue of naloxone on release captures prison
leavers with previous opiate use and other relevant risk factors.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
6. HMPPS notified us of Mr Scott’s death on 3 July 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr Scott’s prison
and probation records.
8. We informed HM Coroner for South Yorkshire West of the investigation. They gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
9. The Ombudsman’s office contacted Mr Scott’s parents to explain the investigation
and to ask if they had any matters they wanted us to consider. They asked for
details of the support Mr Scott had received with his substance misuse while in
prison and the support he received prior to his release. We address these issues in
the report.
10. We shared our initial report with HMPPS and the prison’s healthcare provider,
Nottinghamshire Healthcare NHS Foundation Trust, and We Are With You
Substance Misuse Service. They found no factual inaccuracies. We Are With You
provided an action plan which is annexed to this report.
11. We sent copies of our initial report to Mr Scott’s parents. They did not notify us of
any factual inaccuracies.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Lincoln
12. HMP Lincoln is a category B prison which holds men who have been convicted.
Nottinghamshire Healthcare NHS Foundation Trust provides healthcare, including
mental health services, at the prison. We Are With You provides substance misuse
services.
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, 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.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
Background
14. On 2 September 2022, Mr Matthew Scott was convicted of arson and sentenced to
20 months in prison. He was sent to HMP Moorland.
15. On 1 March 2023, Mr Scott was released from HMP Moorland on Home Detention
Curfew.
16. On 26 January 2024, Mr Scott was recalled to prison for breaching his licence
conditions. He was sent to HMP Lincoln.
17. Mr Scott had a history of drug and alcohol misuse. He was referred to the prison’s
substance misuse service at Lincoln, but he did not engage.
Pre-release planning
18. Mr Scott’s prison offender manager (POM), community offender manager (COM)
and his accommodation support worker (from the charity Roundabout) were in
contact with each other while Mr Scott was at Lincoln. The COM completed
safeguarding and police checks to ensure his accommodation was still suitable. The
prison confirmed to Mr Scott his accommodation in the community was still
available on release.
19. On 14 February, Mr Scott attended a video link call with his COM to discuss his
upcoming release. They discussed his feelings about being released, what had
been happening when he was recalled to prison and how they were going to work
together. When we spoke to Mr Scott’s COM, she said Mr Scott said he was
confident he was accessing the right support. He told her he had self-referred to a
substance misuse service in the community.
20. Mr Scott’s POM and COM did not have a handover meeting before his release, but
they were in contact by email.
21. On 10 June, Mr Scott’s COM provided the prison with his licence conditions (which
included drug testing) and instructions to attend the probation office at 2.00pm on
13 June.
Release from HMP Lincoln
22. On 13 June, Mr Scott was released from Lincoln. Mr Scott reported to the probation
office as instructed and was accompanied by his accommodation support worker
from Roundabout.
23. Mr Scott’s licence expired on 15 June. His post-sentence supervision period began
on 15 June and was due to expire on 16 August.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Circumstances of Mr Scott’s death
24. Mr Scott was found deceased in his accommodation on 17 June. He was found by
a member of staff.
Post-mortem report
25. The post-mortem report concluded that Mr Scott died from multiple drug toxicity.
The toxicology report found evidence of recent use of cocaine, synthetic
cannabinoids (‘Spice’), morphine (an opioid), pregabalin (a prescription drug used
to treat anxiety and nerve pain but also widely abused as it enhances the euphoric
effects of opioids), benzodiazepines (prescription drugs used to treat anxiety but
also widely abused) and alcohol. The pathologist noted that each was at lower than
fatal levels on its own, but the combined cardiorespiratory effects of each would be
highly likely to cause death.
Findings
26. Mr Scott was not offered naloxone (a medication that can rapidly reverse opioid
overdose) prior to his release as he had declined support from the prison’s
substance misuse team in line with local policy. We are concerned that the
provision of naloxone to prison leavers with a history of substance misuse is
inconsistent. We consider that Mr Scott would have been a suitable candidate for
naloxone on release and make the following recommendation:
The Head of Service Delivery for substance misuse should satisfy themselves
that the local policy on the offer and issue of naloxone on release captures
prison leavers with previous opiate use and other relevant risk factors.
27. Mr Scott’s COM identified that Mr Scott’s offending was linked to his substance
misuse, and she agreed to include drug testing as a condition of his licence.
However, there was little time to implement this as his licence ended two days after
he was released.
28. Mr Scott had self-referred to a substance misuse service in the community. We do
not know if he engaged with them during the four days between his release and his
death as it is outside the scope of our investigation.
Adrian Usher
Prisons and Probation Ombudsman April 2025
Inquest
The inquest, held on 15 May 2025, concluded that Mr Scott’s death was drug related.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE