Michael Johnson

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Independent investigation into
the death of Mr Michael Johnson,
on 25 May 2024
following his release from
HMP Altcourse
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, 2025
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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. 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.
3. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
4. Mr Michael Johnson died from mixed drug poisoning on 25 May 2024, following his
release from HMP Altcourse on 23 May 2024. He was 39 years old. We offer our
condolences to those who knew him.
5. Mr Johnson had a history of substance misuse. He was well supported by the
substance misuse team at Altcourse and was promptly referred to the community
substance misuse service for continued support. Mr Johnson was not offered a
naloxone kit prior to being released. The prison have recognised this failing and
have made appropriate changes. The community substance misuse team offered
Mr Johnson a naloxone kit, but he declined. He was given enough methadone to
last over the bank holiday weekend, so he was able to continue with his methadone
prescription.
6. We did not find any significant issues for learning in the pre or post-release
planning. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Johnson’s death on 2 July 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Johnson’s prison
and probation records.
9. We informed HM Coroner for Liverpool of the investigation. He gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
10. The Ombudsman’s office contacted Mr Johnson’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Johnson’s sister
asked the following questions:
• Why was Mr Johnson released after serving three weeks and 3 days and not
10 weeks in prison?
• Why was Mr Johnson released with three bottles of methadone?
We have addressed these questions in our report.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out a factual inaccuracy, and this report has been amended
accordingly.
12. Mr Johnson’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Altcourse
13. HMP Altcourse is a category B prison which holds male prisoners who have either
been convicted or are on remand. It is managed by G4S. G4S provides physical,
mental health and substance misuse services. The clinical and non-clinical teams
are known as Stay Out and Recover (SOAR). Castle Rock Group (CRG) provides
secondary mental healthcare.
Probation Service
14. 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.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Altcourse was in November 2021. Inspectors
reported that all new arrivals were screened for alcohol and drug use and if
necessary, they were referred to a GP, ensuring clinical assessments took place
promptly. However, they found that there was very limited non-clinical SOAR team
support available to provide prisoners with psychosocial support and they
recommended there needed to be effective, joined up non-clinical substance
misuse support available for prisoners.
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Key Events
Background
16. On 29 April 2024, Mr Johnson was convicted of stealing and was sentenced to 20
weeks in prison. He was sent to HMP Altcourse. Mr Johnson was due to be
released on 7 July.
17. A nurse completed Mr Johnson’s initial health screen. Mr Johnson said that he was
an alcoholic and would drink six litres of cider every day. He thought that he was
withdrawing because he was experiencing seizures and shakes. He also said that
he had bi-polar disorder and anxiety. Mr Johnson said he used six bags of cocaine
every day in the community, including the previous day. He also said that he was on
a methadone prescription (an opioid substitution) in the community, which he also
took the previous day, and that he had some methadone with him when he entered
prison. (The drug and alcohol service manager at Altcourse told us that any
methadone that is brought into the prison is destroyed as there are no facilities to
store it, and it would not be re-issued on release.)
18. Mr Johnson’s urine sample tested positive for cocaine and methadone. The nurse
referred him to the substance misuse team.
19. Mr Johnson was prescribed various medications to help him manage his mental
health and substance misuse issues including mirtazapine (antidepressant),
pregabalin (used to treat epilepsy and anxiety), olanzapine (used to treat
schizophrenia), zopiclone (for insomnia), thiamine (vitamin B), and methadone.
20. On 30 April, a nurse completed Mr Johnson’s secondary health screen. Mr Johnson
said that he had used drugs when he was in prison previously and did not deny that
he would continue to use drugs this time. Mr Johnson said that he felt well and that
his current medication helped him with his mental health. She referred Mr Johnson
to the primary care mental health team.
21. Mr Johnson was placed on an alcohol detoxification programme and the substance
misuse team monitored him daily. Mr Johnson said that he felt ok. Healthcare staff
did not note any obvious signs of withdrawal.
22. On 3 May, a nurse completed a joint review with a recovery worker from the
substance misuse team. Mr Johnson was trained in the use of naloxone (a
medication that can reverse the effects of an opiate overdose) and he said he felt
stable on 95ml of methadone. The nurse also noted Mr Johnson showed no signs
of withdrawal. Mr Johnson said that he suffered with anxiety and depression. Mr
Johnson was informed of how he could access help and support and a plan was
made for him to engage with the non-clinical substance misuse team.
23. On 7 May, a GP at the prison reviewed Mr Johnson’s medication because he was
concerned with the amount of medication with sedative effects he was taking, which
he deemed unsafe. The GP noted that there was no clear reason why Mr Johnson
was prescribed pregabalin and put a plan in place to stop his zopiclone and to detox
from pregabalin. On 20 May, Mr Johnson’s prescriptions of pregabalin and
zopiclone were stopped.
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Pre-release planning
24. On 30 April, a worker from the substance misuse team referred Mr Johnson to the
community WAWY (We are With You - a charity that supports people with drug,
alcohol, and mental health issues). He was advised that Mr Johnson should attend
their local service on the day of release, regardless of whether an appointment had
been arranged for him beforehand.
25. On 13 May, Mr Johnson’s allocated Community Offender Manager (COM)
completed a CAS3 referral (provides temporary accommodation for up to 84 nights
for those leaving prison homeless). However, the referral was rejected because it
should only be completed 10 to 15 days before a prisoner’s release date. Mr
Johnson’s expected release date was 7 July.
26. The COM also completed 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) to Liverpool
City Council.
27. On 20 May, the COM saw Mr Johnson. He told her that he was in a lot of pain
because he still had not been given any alternative medication in place of
pregabalin, which he was prescribed for sciatica. He told her that he was having
thoughts of self-medicating with illicit substances because he was in so much pain
and he wanted to work because he was thinking too much about his addictions. She
said that she would email the prison to see what they could do to help Mr Johnson
with his concerns. She also told Mr Johnson that he would need to engage with
WAWY on release and he was happy to do so. That day, she emailed Mr Johnson’s
Prison Offender Manager (POM), who said Mr Johnson would have to speak to the
GP about his medication. She did not mention support with finding a job in prison.
Mr Johnson did not book an appointment with the GP before his release.
28. On 21 May, Mr Johnson was approved for release under the End of Custody
Supervised Licence scheme (ECSL) which allowed prisoners to be released up to
70 days early to ease overcrowding in prisons. Mr Johnson’s new release date was
23 May, in two days’ time. The COM completed another CAS3 referral. However,
this was unsuccessful because they had no bedspaces available for his imminent
release. Liverpool City Council had not responded to the DTR.
29. On 22 May, WAWY sent Mr Johnson an appointment letter to attend their service
before 4.00pm on the day of his release to make sure he continued to receive his
methadone script.
30. Mr Johnson was subject to one additional licence condition to comply with any
requirements set by his probation officer to address his drug use.
Release from HMP Altcourse
31. On 23 May, prior to being released, Mr Johnson was given his last dose of
methadone. He was not offered a naloxone kit. Mr Johnson was then released from
Altcourse under ECSL.
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32. Mr Johnson was not released with any bottles of methadone. He was released with
his prescribed medication, which included mirtazapine (antidepressant), olanzapine
(antipsychotic), thiamine (vitamin B), and diazepam (anxiety medication).
33. Mr Johnson was released homeless.
34. Mr Johnson attended his initial probation appointment with his COM. She
challenged Mr Johnson because he smelled of cannabis. Mr Johnson said that he
had drunk alcohol before coming to his appointment and found cannabis on the
floor which he smoked. He asked if she could change his appointment with WAWY,
and she advised him to attend the appointment that they had given to him so they
could support him. Mr Johnson was given another probation appointment for 30
May.
35. During the appointment, the COM called Whitechapel Centre (homeless and
housing charity) to see if they could support Mr Johnson with accommodation. They
were not able to help but provided her with their out of hours assistance number
and provided the out of hours number for housing options emergency
accommodation. She gave the numbers to Mr Johnson so that he could call the out
of hours service. We do not know if Mr Johnson found any accommodation for his
first nights after release.
36. On 24 May, Mr Johnson attended his appointment with WAWY and he was given
his methadone prescription. However, WAWY were not able to allocate Mr Johnson
to a chemist that was open seven days a week before the bank holiday, so they
gave him enough methadone to last him over the holiday weekend. Mr Johnson
was offered a naloxone kit to take with him, but he declined.
Circumstances of Mr Johnson’s death
37. At 9.00am on 25 May 2024, a member of the public found Mr Johnson lying on the
floor in a doorway and called the emergency services. When the paramedics
arrived, they concluded that Mr Johnson was already dead. Drug paraphernalia was
found at the scene.
Post-mortem report
38. The post-mortem report concluded that Mr Johnson died from mixed drug
poisoning.
39. The toxicology report concluded Mr Johnson had consumed methadone, various
prescription medications, cannabis, Spice (a psychoactive substance), cocaine and
morphine prior to his death.
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Findings
Substance misuse services
40. Mr Johnson had a history of substance misuse. While in prison, the substance
misuse team saw him regularly and he was warned about the risks and dangers of
taking drugs. He was shown how to use a naloxone kit, but he was not offered a
naloxone kit on release as he should have been.
41. A substance misuse worker said that the prison did not offer Mr Johnson naloxone
on release in error, and they have now made several changes to avoid opiate-using
prisoners being released without naloxone. The discharge template has been
changed to prompt the nurse completing the form to offer and discuss naloxone
with any patient prescribed Opiate Substitute Treatment (OST).
42. There is now a member of the substance misuse team in reception during normal
hours to see all their service users and they check who has been offered naloxone,
who has taken naloxone and will also try and promote those being released to take
naloxone with them. The substance misuse team will raise any concerns about
anyone they feel may need a naloxone kit.
43. The reception nurses are now aware of how to easily spot who is working with the
psychosocial team and there is a tabbed journal on the medical database which
shows all the entries made by the substance misuse team, so these can be
checked easily. This allows the nurses to check the prisoner’s engagement and
decide whether to offer a naloxone kit before they are released.
44. The substance misuse team manager and the Head of Healthcare are currently
trialling offering nasal naloxone, rather than injectable naloxone, to prisoners, to see
if it increases the number of prisoners taking a naloxone kit with them on release.
45. The prison’s substance misuse team promptly referred Mr Johnson to the
community drug and alcohol service, to ensure he was provided with ongoing
support and he continued his methadone prescription in the community.
46. We are satisfied that Altcourse and the Probation Service did all they could to
manage the risks associated with his substance misuse. Although the prison did not
offer Mr Johnson naloxone, we are satisfied they have made adequate changes to
ensure that this failure does not happen again. We make no recommendation.
Accommodation
47. Homelessness on release from prison is a significant and complex challenge. While
prison and probation staff can submit referrals to local authorities and charities,
there are occasions when beds are not available, or the individual does not meet
the eligibility criteria for housing. This means that these individuals are released
homeless and are expected to report to the local authority on the day of their
release in the hope of receiving emergency housing. If an individual is homeless, it
can increase the likelihood that they will commit further crimes or seek shelter and
support in harmful places.
48. Mr Johnson was released from prison without any suitable accommodation. His
release under ECSL was confirmed just two days before his release date, giving his
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COM little time to make referrals and source accommodation for him. We consider
that staff took appropriate steps to identify accommodation for him, but sadly, it
appears that he had not done so, or not been able to do so before his death. We
make no recommendation.
Inquest
49. At the inquest held on the 9 September 2024, the coroner concluded Mr Johnson’s
cause of death was drug related.
Adrian Usher
Prisons and Probation Ombudsman February 2025
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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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