Mohamed Izem

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Independent investigation into
the death of Mr Mohamed Izem,
on 20 February 2024,
following his release from
Harmondsworth IRC
A report by the Prisons and Probation Ombudsman
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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 the Home Office 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. Mr Mohamed Izem, a foreign national from Algeria, died from MDMA toxicity on 20
February 2024 following his release from Harmondsworth Immigration Removal
Centre (IRC) the previous day. (MDMA is a class A, synthetic drug, commonly
known as ‘ecstasy’.) He was 22 years old. I offer my condolences to those who
knew him.
4. The Home Office’s Electronic Monitoring (EM) Team did not inform Harmondsworth
IRC that Mr Izem was to be released until the day of his release. This could not
have been prevented and we make no recommendation about this.
5. Mr Izem was not referred to the psychosocial substance misuse service following
his reception screening because he did not disclose a history of drug use. A GP
saw Mr Izem a day later and he disclosed previous drug use, however as he had
already been referred to the integrated mental health team (which the substance
misuse service was part of at the time) the GP assumed that they would have
picked this up and did not make a further referral. The Head of Healthcare told us
that the services had been separated since Mr Izem’s death, therefore we do not
make a recommendation about this.
Head of Healthcare to note
6. Although Mr Izem needed a follow-up mental health appointment, the healthcare
team did not contact the Home Office to arrange the appropriate multidisciplinary
team meeting to discuss Mr Izem. However, as this was not related to the cause of
Mr Izem’s death and the relevant guidance has since been updated, we do not
make a recommendation.
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The Investigation Process
7. The Home Office notified us of Mr Izem’s death on 23 February 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Izem’s prison
and probation records.
9. We informed HM Coroner for Camden of the investigation. She gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
10. The Ombudsman office contacted Mr Izem’s next of kin, his partner, to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked for a copy of the report.
11. Mr Izem’s next of kin received a copy of the draft report. They did not make any
comments.
12. The initial report was shared with the Home Office and Practice Plus Group.
Practice Plus Group pointed out some factual inaccuracies and this report has been
amended accordingly.
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Background Information
Harmondsworth IRC
13. Harmondsworth is an immigration removal centre for adult male detainees. It is
managed by Mitie Group and its healthcare provider is Practice Plus Group.
Probation Service
14. 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.
HM Inspectorate of Prisons
15. The most recent inspection of Harmondsworth IRC was in February 2024.
Inspectors reported that the standard had fallen further since their previous
inspection in 2017 and the score for safety and respect had declined from not
sufficiently good to poor.
16. Inspectors found that drug use had become an increasingly serious problem and
outcomes for detainees were not sufficiently good for preparation for removal and
release. HMIP specifically referred to Mr Izem’s case and noted that a
multidisciplinary team meeting was not convened to make sure appropriate
arrangements were made for his safe release.
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Key Events
17. On 11 August 2021, Mr Mohamed Izem, a foreign national from Algeria, was
charged with robbery and remanded to HMP Thameside.
18. On 23 March 2022, Mr Izem was convicted of robbery and sentenced to seven
years and six months in prison. His sentence was later reduced by the Court of
Appeal to five years and five months.
19. Mr Izem had a history of substance misuse, epilepsy, anxiety and depression.
Pre-release planning
20. On 29 June 2022, Mr Izem was transferred to HMP Feltham. During his reception
screen with Nurse C, he reported that he had no problems with drugs and alcohol.
21. On 30 June, Mr Izem saw Nurse A. He disclosed a history of cannabis use but said
he had no history of using class A drugs. He declined a referral to the substance
misuse service. An assistant psychologist referred Mr Izem to the mental health
team, following discussion at a multidisciplinary team (MDT) meeting. Mr Izem
remained under the care of the mental health team whilst he was at Feltham.
Harmondsworth IRC
22. On 12 January 2024, Mr Izem was released from Feltham and admitted to
Harmondsworth IRC, as he was a Foreign National Offender (offender identified as
being of interest to Home Office Immigration Enforcement and is therefore liable for
deportation.) Nurse B completed his initial health screen in reception, and he
reported a history of epilepsy. Mr Izem also reported that he had stress and anxiety.
The Nurse B referred him to the integrated mental health team, which consisted of
the mental health team, the clinical and psychosocial substance misuse service and
psychology. Mr Izem said that he had not previously used drugs. Head of
Healthcare told us that at the time, the substance misuse service was part of the
integrated mental health team and meetings regularly took place to discuss onward
referrals.
23. On 13 January, a clinical practitioner saw Mr Izem as part of an assessment to
determine whether he was vulnerable (to assist with decisions about whether
continued detention is appropriate and to manage risk). Mr Izem disclosed that he
had misused drugs in the past. The Head of Healthcare told us that as a clinical
practitioner noted that Mr Izem had been referred to the integrated mental health
team, a further referral to the psychosocial substance misuse team was not
completed.
24. On 15 January, Mr Izem was referred to the National Referral Mechanism (NRM
which identifies and refers potential victims of modern slavery for support).
25. On 18 January, Nurse D, a mental health nurse, saw Mr Izem for a mental health
inreach review and noted that Mr Izem was taking antipsychotic medication. The
integrated mental health team met to discuss onward referrals for Mr Izem and he
was added to the mental health caseload and psychology waiting list to support his
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PTSD. As these referrals were based on what had been raised during the reception
screening, he was not added to the psychosocial substance misuse waiting list.
26. On 19 January, an immigration judge granted Mr Izem bail on the condition that he
lived at an address approved by the probation service and that he wore an
electronic tagging device. (His bail was not to start until an address had been
approved.)
27. The pharmacy team tried to phone Mr Izem about not complying with his medication
but he did not answer. They therefore sent him a message to remind him about his
medication.
28. On 22 January, Mr Izem’s Community Offender Manager contacted Mr Izem. He
told him that he had been granted bail and had 28 days to find accommodation or
he would have to re-apply. Mr Izem’s Community Offender Manager told Mr Izem
that it would be difficult to find accommodation but all avenues would be explored.
Mr Izem’s solicitor told Mr Izem’s Community Offender Manager that they had
submitted an application to the Home Office for accommodation for asylum seekers
which the Probation Service needed to assess. They said that the Home Office
should contact Mr Izem’s Community Offender Manager once they had found
suitable accommodation.
29. On 29 January, Mr Izem phoned Mr Izem’s Community Offender Manager and told
him that his partner had found an address and would fund the accommodation. Mr
Izem’s Community Offender Manager told Mr Izem that the Probation Service
needed first to assess the address.
30. On 9 February, a public order disqualification was served on Mr Izem. (This meant
that Mr Izem was deemed a threat to public order which disqualified him from NRM
support.) A clinical practitioner submitted a report to the Home Office that Mr Izem
might have been a victim of torture and was therefore vulnerable.
31. On 10 February, MH Nurse E saw Mr Izem for a mental health assessment. He told
her he had a history of using illicit substances. MH Nurse E referred him to the
substance misuse service. MH Nurse E told us that she did not have any significant
concerns about Mr Izem and he was looking forward to being released.
32. On 12 February, an Adults at Risk assessment took place in response to a clinical
practitioner’s report. It concluded that Mr Izem’s risk was assessed as Level 3. This
meant that there was evidence that he was at risk of harm if he were to remain in
detention. As an immigration judge had already granted Mr Izem conditional bail, no
further action was taken.
33. On 13 February, Mr Izem’s Community Offender Manager phoned Mr Izem’s
partner to discuss the address she had found for him. She said she had told the
landlord that Mr Izem was under probation supervision. She said that there would
be difficulties funding the accommodation and asked if the Probation Service could
support him. Mr Izem’s Community Offender Manager told her that this was difficult
because of Mr Izem’s immigration status but that support would be given, where
possible.
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34. On 14 February, Mr Izem’s Community Offender Manager asked for police checks
to be completed on the address provided by Mr Izem’s partner.
35. On 15 February, Mr Izem did not attend his psychiatric appointment with Dr B,
despite him ringing several times. Dr B noted concerns that Mr Izem was not always
compliant with his medication which put him at risk of seizures. A principal
pharmacist told us that Mr Izem did not take his medications as regularly as
prescribed, but healthcare staff always intervened when medications were missed
and made doctors aware. The principal pharmacist said that Mr Izem was often
contacted, and would agree to attend for his medication but did not always do so.
36. On 16 February, Mr Izem collected his medication from the healthcare unit. The
judge removed the requirement for accommodation to be provided from Mr Izem’s
bail. This meant that Mr Izem had to be released from the IRC within 72 hours.
37. At 3.49pm, Mr Izem’s case was referred to the electronic monitoring (EM) team to
arrange his release. The Operation Lead for the EM team, told us that due to the
lateness of the referral, the case was not picked up until the next working day, 19
February.
Post-release
38. On 19 February, the EM team notified Mr Izem’s Community Offender Manager, the
Detention Engagement Team (DET) and the healthcare team that Mr Izem would
be released that day. Mr Izem’s Community Offender Manager tried to call Mr Izem
but he did not answer. The Head of Healthcare told us that an MDT meeting was
not necessary to discuss Mr Izem’s release as he did not pose a risk to himself or
others. The Area Manager for the DET told us that they had no significant concerns
about Mr Izem’s release so did not arrange an MDT meeting.
39. MH Nurse E called Mr Izem to ask him to attend a pre-release review so that she
could advise him where he could get mental health support in the community. He
told her that he would visit the healthcare unit, but he did not attend before he was
released. MH Nurse E tried to call him again to advise him to register with a GP, but
his phone went to voicemail.
40. The substance misuse team called Mr Izem to discuss their services. He told them
that he was interested in accessing their support but said he was waiting for the
Home Office to contact him and asked if they could call him back. The medical
records noted that the team had no concerns and that Mr Izem had presented in
good spirits. The Team Manager for Forward Trust (a substance misuse charity)
told us that they usually try to see people within five days of a referral being made.
However, this was not always possible due to resource issues, and at the time, the
team only consisted of three staff members.
41. The Salvation Army contacted Mr Izem and told him that they had secured a safe
house for him. He told them that he was being released to his cousin’s address.
Arrangements were made for the Modern Slavery Team to contact Mr Izem the
following day to discuss if he wanted to live at the safe house or at his cousin’s
address. Mr Izem was bailed out of the IRC later that evening, and his cousin
picked him up from the IRC. He was given his medication, his medical notes, some
money and a travel warrant before his release.
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42. On 20 February, MH Nurse E tried to call Mr Izem but his phone went to voicemail.
Therefore, she wrote to him to advise him to register with a GP so he could be
referred to community mental health services. The substance misuse team at the
IRC tried to call Mr Izem to refer him to community substance misuse service but
were informed that he had been released the previous day. The referral was
therefore closed. (The Team Manager for Forward Trust told us that they could only
have referred Mr Izem to a community substance misuse service if he had
completed an assessment with Forward Trust and signed the consent forms.)
43. Mr Izem’s Community Offender Manager tried to contact Mr Izem through his
partner’s phone number. His partner told Mr Izem’s Community Offender Manager
that she had not spoken to him for a few days and was unaware that he had been
released. Senior Probation Officer A told us that there was no evidence that a
probation induction had been arranged for Mr Izem and it is likely that this was due
to the last-minute release and not being able to contact Mr Izem.
Circumstances of Mr Izem’s death
44. On 20 February, Mr Izem’s cousin and friend told the police that they had gone to a
hotel with Mr Izem the previous evening and had woken up at around 10.00am on
20 February. They said they heard Mr Izem murmur and put a blanket on him
before they left the hotel. At around 3.00pm, they returned to the hotel room and
found Mr Izem in bed. They tried to wake him but realised his face was purple, he
was cold to touch and had no pulse. They immediately alerted the front desk to call
for emergency services. Paramedics pronounced life extinct at 3.41pm.
45. On 21 February, the Home Office contacted Mr Izem’s Community Offender
Manager to say that they had heard that Mr Izem had died. Mr Izem’s Community
Offender Manager contacted Mr Izem’s partner who confirmed that Mr Izem had
died.
Post-mortem report
46. The post-mortem report concluded that Mr Izem died of MDMA toxicity. The post-
mortem report stated that alcohol, caffeine, nicotine, clonazepam, cannabis and
morphine were also present but were unlikely to have contributed to Mr Izem’s
death.
47. The toxicology results could not determine whether Mr Izem’s seizure activity was
under control at the time of death, but the post-mortem report noted that the
absence of epilepsy medication in his system could be consistent with non-
compliance. The neuropathological, histological and macroscopic examination
showed no other significant abnormality to suggest an alternative cause of death.
Inquest
48. At an inquest held on 21 August 2025, the Coroner concluded that Mr Izem’s death
was drug related.
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Findings
Substance misuse
49. During his reception screening, Mr Izem was referred to the integrated mental
health service, consisting off the mental health team, the clinical and psychosocial
substance misuse service and psychology. Mr Izem reported that he had not
previously used drugs. The following day during his appointment with a clinical
practitioner, he reported a history of drug use. The Head of Healthcare told us that
he was not referred to the psychosocial substance misuse service at this point as
he was awaiting review from the integrated mental health team.
50. The integrated mental health team met on 18 January, and Mr Izem was added the
mental health caseload and psychology waiting list. He was not referred to the
psychosocial substance misuse service as the referrals were based on the
concerns that had been raised during his reception screening.
51. When MH Nurse E saw Mr Izem on 10 February, he reported a history of drug use,
and she referred him to the psychosocial substance misuse service. Unfortunately,
the team were unable to see Mr Izem before his release from Harmondsworth.
52. The Head of Healthcare told us that since Mr Izem’s death, the services have been
separated, and referrals are completed to the mental health team and the
substance misuse service separately. He said that as soon as somebody is referred
to these services, they are added to a specific caseload. This would have avoided
the assumption that A clinical practitioner made that Mr Izem was going to be
referred to the substance misuse service following the integrated mental health
team meeting. In light of this change, we do not make a recommendation.
Release planning
53. Harmondsworth IRC was not informed that Mr Izem was to be released until the day
of his release. This meant that the substance misuse team was unable to see him
and refer him to the community service before his release. When the substance
misuse team phoned Mr Izem on 19 February to discuss their services, they were
not aware that he was going to be released later that day. They did not therefore
offer him naloxone or harm reduction advice during this phone call. When the
substance misuse team called him the following day, they found out he had been
released.
54. Mr Izem’s Community Offender Manager was also not informed of Mr Izem’s
release until 19 February. This meant that a probation induction appointment was
not arranged before Mr Izem’s release which would have given him a further
opportunity to discuss his substance misuse and be referred to a community
service.
55. Mr Izem was released before the Salvation Army was able to offer him
accommodation (but was bailed to his cousin’s address). The Salvation Army
contacted him on 19 February once they had found him accommodation and he
confirmed he was at his cousin’s address. He was told a safe house was available
and was given until 10.00am the following day to decide whether he wanted to stay
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at his cousin’s address or the proposed safe house. The Salvation Army tried to
contact him the following day but by then, Mr Izem had died.
56. Mr Izem’s case was not referred to the EM team until 3.49pm on 16 February. The
EM team reasonably picked up the referral on the next working day, 19 February,
the day of Mr Izem’s release. An immigration bail officer told us that immigration bail
cases have a 72-hour window to arrange release. He said that it can often be
difficult to arrange release for people bailed on a Friday as there are no staff
available at the weekend, even though weekend hours count towards the 72-hour
window. In light of this, we do not make a recommendation.
Head of Healthcare to note
57. At the time of Mr Izem’s death, Detention Services Order (DSO): Managing Adults
at Risk in Detention 08/2018 stated that in cases where IRC or healthcare staff
have significant concerns about planned releases who are considered at risk - for
example, if the detained individual requires a mental health follow-up appointment –
the local DET must arrange an MDT meeting to agree a safe release plan.
58. Our investigation highlighted a gap in communication for an MDT meeting to be
arranged. The Home Office told us that the usual process was for the healthcare
team to communicate concerns about a detainee’s vulnerability/risk to the DET so
that an MDT discussion can be arranged. The DET told us that the healthcare team
had not highlighted to them any concerns about Mr Izem. However, the Head of
Healthcare told us that it would be good practice – rather than standard procedure -
to notify the DET if they had concerns about a release.
59. While the Head of Healthcare told us that an MDT meeting was not necessary for
Mr Izem as he did not pose a known risk to himself or others, he was prescribed
antipsychotic medication and would therefore have needed a mental health follow-
up appointment and a referral to the community mental health team. The Home
Office said they would have expected healthcare staff to raise this with them.
60. We note that the mental health team tried to contact Mr Izem to attend a pre-
release review and organise support for him in the community but he did not attend.
As Mr Izem’s death was drug-related, it is unlikely that an MDT meeting would have
affected the outcome.
61. The Home Office told us that since Mr Izem’s death, they have updated DSO
08/2018. It now states that in cases where staff (anybody working in the centre,
including healthcare staff) have significant concerns about planned releases who
are considered at risk - for example, if the detained individual requires a mental
health follow-up appointment - the DETs must be informed at the earliest possible
opportunity so that they can arrange an MDT meeting to agree a plan to release the
individual safely. This change provides clarity about responsibilities when arranging
MDT meetings ahead of release.
62. The Home Office said that they planned to roll out awareness sessions about this
DSO to ensure that all staff understood the changes to the published guidance,
including the circumstances when an MDT meeting is needed. In light of the above,
we do not make a recommendation.
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Adrian Usher
Prisons and Probation Ombudsman July 2025
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