Neil West

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Independent investigation into
the death of Mr Neil West,
on 4 June 2024,
following his release from
HMP Nottingham
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. 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. On 4 June 2024, Mr Neil West died from a severe brain injury, caused by a cardiac
arrest, which in turn was caused by suspected/unknown substance misuse. Mr
West had been released from HMP Nottingham 12 days earlier. He was 51 years
old. We offer our condolences to those who knew him.
5. Probation staff made efforts to address Mr West’s substance misuse and put
appropriate licence conditions in place. Despite the Probation Service’s efforts, a
video-link meeting between Mr West, his community offender manager and prison
offender manager was not organised to plan for his release. Had a meeting been
scheduled with Mr West, the COM would have known where Mr West wanted to be
released to and he could have facilitated substance misuse referrals earlier.
However, there is no evidence that Nottingham received the email requests for a
meeting.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr West’s death on 11 September 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr West’s prison
and probation records.
9. We informed HM Coroner for Nottingham of the investigation. They gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
10. Mr West did not have a named next of kin and we were therefore not able to contact
anyone about our investigation into his death.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Nottingham
12. HMP Nottingham is a category B reception prison which holds men who have been
convicted or remanded into custody. Nottinghamshire Healthcare Foundation Trust
provides healthcare, including mental health and substance misuse services, at the
prison.
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
appropriate. Post-release, the Probation Service supervises people throughout their
licence period and post-sentence supervision.
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Key Events
Background
14. On 28 March 2024, Mr Neil West was sentenced to 17 weeks in prison for
breaching his sexual harm prevention order. He was sent to HMP Nottingham.
15. During his initial health screen, he told healthcare staff that he drank 10 units of
alcohol a day, he had last used Mamba (a psychoactive substance) the previous
day and had used crack cocaine a week earlier. He reported no thoughts of suicide
and self-harm but had a history of depression, for which he was prescribed
mirtazapine which he felt was working well. He refused mental health and
substance misuse referrals and was ‘adamant he would ‘keep himself safe’.
Healthcare staff discussed harm reduction strategies with him, and he was told how
to refer himself for support, if needed.
16. That day, during a key work session with an officer from the safer custody team, Mr
West again declined a referral to the substance misuse service and said he would
manage without one. They discussed harm reduction and the risk of using
substances in prison.
17. Also that day, the substance misuse team saw Mr West. He refused support for his
alcohol consumption.
18. On 1 April, during a key work session with an officer who worked in the first night
centre at the time, Mr West said that he used alcohol and drugs and was receiving
specialist help in the community.
19. On 3 April, Mr West’s community offender manager (COM) emailed the service
manager of Hope House (a homelessness charity that provides accommodation in
Worksop in Nottinghamshire), where Mr West had lived before going to prison. He
told her that Mr West had been convicted. She agreed to keep his bedspace open
for him.
20. On 11 April, Mr West saw a probation services officer for a resettlement interview.
He told her that he would be homeless on release and gave consent for
accommodation referrals to be made to HMPPS’ Commissioned Rehabilitative
Services (CRS, which provides support services to prison leavers) and the local
authority under the statutory duty to refer those at risk of homelessness. That day,
she emailed the COM to ask him to submit these referrals for Mr West. The COM
told the investigator that he did not complete them, as he had arranged for Mr
West’s space at Hope House to remain available to him.
21. On 17 April, the COM’s administrative assistant tried to arrange a video-link
meeting so that Mr West, his COM and his prison offender manager (POM) could
plan for his release. She sent a meeting request through a system called Jitbit (a
ticketing software used in the East Midlands probation region which enables the
user to send and receive emails).
22. The administrative assistant contacted the prison by phone on 23 April to check
whether they had received the meeting request by email. The prison had not
received an email request and therefore had not responded. They told us that if
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they had received an email to request a meeting, they would have facilitated a
video-link call.
23. On 20 April, the prison resettlement team booked an appointment for Mr West at
the job centre for 24 May. Records indicate that Mr West was told about this
appointment but we do not know whether he attended.
24. On 24 April, the COM emailed the POM to discuss Mr West’s accommodation at
Hope House and confirm whether Mr West wanted to return there. The COM told
the investigator that he then spoke to her but could not recall their discussion.
25. On 2 May, the COM emailed the service manager to let her know that Mr West’s
scheduled release date was 23 May.
26. On 13 May, a member of staff at Nottingham’s Careers, Information, Advice and
Guidance Team conducted a pre-release interview with Mr West. He told Mr West
that he had been referred to the local authority for the Chesterfield area (in case he
did not want to remain at Hope House in Worksop) under the statutory duty to refer
those at risk of homelessness.
Release from HMP Nottingham
27. On 23 May, Mr West was released from Nottingham. He declined to see healthcare
staff before release which meant he was released without his mirtazapine
prescription. The Head of Healthcare told the investigator that Mr West could have
collected his mirtazapine from his GP post-release. He also told the investigator that
Mr West was not offered naloxone (a medication that rapidly reverses an opioid
overdose) because he had not disclosed a history of opiate use.
28. Mr West reported to his probation office for an initial appointment with his COM. Mr
West signed his licence, which included a drug-testing and alcohol tag condition.
The COM discussed referring Mr West to Change Grow Live (CGL, a substance
misuse support service). The COM told the investigator that Mr West did not seem
keen to be referred. The COM told him that he would need to present at Hope
House daily from 5.00pm until he could have an alcohol monitoring tag fitted. They
agreed to discuss and complete a substance misuse referral at his next
appointment. Following the appointment, Mr West left for Hope House, where he
lived until his death.
29. Neither Nottingham nor the COM referred Mr West to any community substance
misuse or mental health services. Nottingham told the investigator that Mr West had
declined to engage with services, and his depression was historic. The COM told
the investigator that he had not completed a substance misuse referral as he was
not sure whether Mr West planned to live in Chesterfield in Derbyshire or Worksop
in Nottinghamshire which were covered by two different services.
30. On 31 May, Mr West failed to attend a probation appointment with his COM, who
subsequently asked for an enforcement letter to be sent.
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Circumstances of Mr West’s death
31. At 1.20pm on 31 May, paramedics were called to a town centre in Nottinghamshire
after Mr West went into cardiac arrest. When they arrived, Mr West’s friends were
trying to resuscitate him and had also administered naloxone. The paramedics took
over resuscitation efforts. Mr West’s friends told the paramedics that they had seen
Mr West putting lighter gas fluid into a cloth and inhaling it. The paramedics noted
that they smelt alcohol on Mr West. He was taken to hospital and placed on a
ventilator.
32. The hospital stated that Mr West had a gastric bleed, commonly caused by stomach
ulcers, which happen as a result of alcoholism. The hospital conducted a drug
toxicology test, the result of which was clear.
33. On 4 June, it was suspected that Mr West had brain damage from the cardiac
arrest. Hospital doctors decided to withdraw treatment, and the ventilators were
switched off and Mr West died around 10 minutes later.
Cause of death
34. A hospital doctor established that Mr West died from severe brain injury. This was
caused by a cardiac arrest which in turn was caused by suspected/unknown
substance misuse. A post-mortem examination and toxicology tests were not
carried out as the Coroner accepted the cause of death provided by the doctor.
Inquest
35. At an inquest held on 24 June 2024, the Coroner concluded that Mr West’s death
was drug related.
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Findings
Mr West’s cause of death
36. The hospital doctor identified suspected/unknown substance misuse as having
ultimately caused Mr West’s death. Mr West’s friends had told paramedics that they
had seen him sniffing lighter gas fluid before he was admitted to hospital. It is likely
that he continued to take substances in the community post-release. Although Mr
West declined substance misuse support in custody and in the community, prison
staff appropriately signposted him to services and gave him harm reduction advice
while in custody. Healthcare staff were not able to prescribe his mirtazapine or
remind him of the risks of taking drugs on release as he declined to see them
before he left prison.
Post-release management
37. The COM put in place reasonable measures to address Mr West’s substance
misuse issues on release. This included adding licence conditions for drug testing
and an alcohol tag.
38. Although the COM included a licence condition for Mr West to comply with any
requirements relating to addressing his substance misuse, his licence did not
provide details of a drug testing and support service for him to access. The COM
told the investigator that this was because he did not know which area Mr West
planned to live in – Worksop or Chesterfield - which were in two separate
catchment areas for substance misuse services: CGL in Worksop or Derbyshire
Recovery Partnership in Chesterfield. If he had put one of the services in the
licence condition, it would have required a formal licence variation to change the
licence details. Mr West was already known to both substance misuse services, and
was referred to CGL Worksop by a member of staff at Derbyshire Recovery
Partnership before he went to prison.
39. The COM told the investigator that he planned to refer Mr West to community
substance misuse services once he had been released and confirmed where he
planned to live in the initial appointment. He told the investigator that their initial
priority was to explain the licence conditions and discuss his accommodation (which
he had in place). As Mr West had to attend Hope House by 5.00pm, they planned to
complete a referral at his next appointment the following week but Mr West had not
attended.
40. The COM had secured accommodation for Mr West at Hope House (where he lived
before coming to prison) in the event that Mr West chose to remain in that area, and
this was where Mr West lived after his release from prison.
Governor and Head of Probation Delivery Unit to note
Video-link appointments
41. Video-link calls are an important tool for pre-release planning. As community
offender managers have little knowledge of a prison leaver’s time in custody,
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meetings by video-link can help to establish their wishes for post-release and
provide an opportunity to discuss pre-release planning and post-release supervision
with the prison offender manager.
42. The COM told the investigator that he spoke to the POM remotely on Microsoft
Teams, but ultimately could not speak to Mr West while he was in custody. He told
the investigator that because he could not speak to Mr West, he was not sure
where he planned to live once he was released from prison. This made it difficult for
him to arrange a substance misuse referral to the right service before Mr West’s
release.
43. The novel use of Jitbit for communication may have played a role in why
Nottingham did not appear to have received the video-link request by email as
although there is some evidence that an email request was sent, Nottingham had
no evidence to suggest the email (sent through the Jitbit system) had been
received. Had a meeting been scheduled with Mr West, the COM would have
known where Mr West wanted to be released to and he could have facilitated
substance misuse referrals for the appropriate area earlier.
Adrian Usher
Prisons and Probation Ombudsman May 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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